Opinion Number ( 1994 )

Dear Representative Lancaster:

Your opinion request of April 26, 1994 has been referred to me for reply. In your request, you ask whether the provisions of R.S. 22:215.15 apply to Health Maintenance Organizations (HMOs).

The provisions of R.S. 22:215.15 mandate the payment of certain benefits for Attention deficit/hyperactivity disorders. Subsections A, C and D deal with the applicability of this law to certain entities. These provisions state:

"215.15. Attention deficit/hyperactivity disorder; coverage; diagnosis

A. Any hospital, health, or medical expense insurance policy, hospital or medical service contract, employee welfare benefit plan, health and accident insurance policy, or any other insurance contract of this type, including a group insurance plan, or any policy of group, family group, blanket, or franchise health and accident insurance, and a self-insurance plan, which is delivered or issued for delivery in this state on or after January 1, 1994, shall include benefits payable for diagnosis and treatment of attention deficit/hyperactivity disorder as provided in this Section. These benefits shall be payable under the same circumstances and conditions as benefits are paid under those policies, contracts, benefit plans, agreements, or programs for all other diagnoses, illnesses or accidents.

* * * *

C. This Section shall apply to any new policy, contract, program or plan issued on or after January 1, 1994. Any policy, contract, or plan in effect prior to January 1, 1994, shall convert to conform to the provisions of this Section on or before the renewal date thereof but in no event later than January 1, 1995.

D. The provisions of this Section shall not apply to individually underwritten, guaranteed renewable limited benefit, supplemental health insurance policies."

While the applicability of this section may seem to be broad, it should be noticed that there is no specific reference to HMOs in this section. Neither does this section state it shall not apply to HMOs.

The provisions of R.S. 22:2001, et seq, govern the certification and regulations of HMOs in Louisiana. R.S. 22:2002(7) defines a Health Maintenance Organization as follows:

"(7) ``Health Maintenance Organization' means any corporation organized and domiciled in this state which undertakes to provide or arrange for the provision of basic health care services to enrollees in return for a prepaid charge. The health maintenance organization may also provide or arrange for the provision of other health care services to enrollees on a prepayment or other financial basis. Notwithstanding any laws, regulations, or definitions contained in any other section of Title 22 to the contrary, a health maintenance organization is deemed to be an insurer for the purposes of liquidation, conservation, rehabilitation, and/or receivership all as defined and set out within Title 22. A health maintenance organization shall not be considered an insurer for any other purpose." (Emphasis supplied)

Reference must also be made to the provisions of R.S. 22:2016(A) which states, in applicable part:

"Statutory construction; relationship to other laws

A. Except as otherwise provided in this Part, provisions of the insurance law and provisions of Part IV of Chapter 1 of Title 2 of the Louisiana Revised Statutes shall not be applicable to any health maintenance organization granted a certificate of authority under this Part. . . ."

Based upon the provisions of R.S. 22:2002(7) and the provisions of R.S. 22:2016(A), it is the opinion of this office that R.S.22:215.15 relative to the payment for the diagnosis and treatment of attention deficit/hyperactivity disorders is not applicable to Health Maintenance Organizations.

If this office can be of further assistance, please advise.

Very truly yours,

RICHARD P. IEYOUB Attorney General

BY: TOMMY D. TEAGUE Assistant Attorney General