Louisiana Revised Statutes 22:1210
NOTE: See Subsection F and La. Rev. Stat. 22:1203(E)(2) regarding eff. date of this Section.
Terms Used In Louisiana Revised Statutes 22:1210
- Board: means the board of directors of the plan. See Louisiana Revised Statutes 22:1202
- Commissioner: means the commissioner of insurance. See Louisiana Revised Statutes 22:1202
- Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
- Fiscal year: The fiscal year is the accounting period for the government. For the federal government, this begins on October 1 and ends on September 30. The fiscal year is designated by the calendar year in which it ends; for example, fiscal year 2006 begins on October 1, 2005 and ends on September 30, 2006.
- Health maintenance organization: means an organization as defined in Louisiana Revised Statutes 22:1202
- Hospital: means any facility as defined in Louisiana Revised Statutes 22:1202
- Insured: means any natural person domiciled in this state, other than a member of the plan, who is eligible to receive benefits from any insurer or insurance arrangement as defined in this Section. See Louisiana Revised Statutes 22:1202
- Insurer: means any insurance company or other entity authorized to transact and transacting health and accident insurance business in this state. See Louisiana Revised Statutes 22:1202
- Medicaid: means coverage provided under the state plan for Title XIX of the Social Security Act, 42 USC 1396 et seq. See Louisiana Revised Statutes 22:1202
- Medicare: means coverage under both Parts A and B of Title XVIII of the Social Security Act, Louisiana Revised Statutes 22:1202
- Plan: means the Louisiana Health Plan as created in Louisiana Revised Statutes 22:1202
- Plan of operation: means the plan of operation of the plan, including articles, bylaws, and operating rules, adopted by the board pursuant to Louisiana Revised Statutes 22:1202
- Self-insurer: means a natural or juridical person which provides health care services or reimbursement for all or any part of the costs of health care for its employees or participants in this state other than through an insurer. See Louisiana Revised Statutes 22:1202
A.(1) For the purposes of this Section, “participating insurer” includes any insurer providing insurance, as defined by La. Rev. Stat. 22:1209(F), to citizens of this state.
(2)(a) For the purposes of this Section, fees assessed to participating insurers shall apply to gross premiums for hospital and medical expense incurred policies, nonprofit service plan corporation contracts, hospital-only coverage, medical and surgical expense policies, major medical insurance, coverages provided by health maintenance organizations, individual practices, associations, and every insurance appertaining to any portion of medical expense liability incurred under a group health plan as defined in La. Rev. Stat. 22:1061(1)(a), including stop-loss and excess-loss coverage unless the gross premium for the coverage is included under any other type of coverage stated in this Section that is issued for delivery in this state.
(b) The fees assessed to participating insurers shall also apply to the same or similar services as provided for in Subparagraph (a) of this Paragraph when the services are administered by a third-party administrator on behalf of a plan that is not fully insured by a health insurance issuer, health maintenance organization, or group self-insurer. For the purposes of third-party administrators, “major medical insurance” shall not include the provision of pharmacy benefits by a third-party administrator or by a health insurance issuer or health maintenance organization when the pharmacy benefits provisions do not include comprehensive coverage.
(c) Fee assessments to participating insurers shall not apply to policies or contracts for provision of short-term, accident-only, hospital indemnity, credit insurance, automobile and homeowner’s medical-payment coverage, workers’ compensation medical benefit coverage, Medicare, Medicaid, federal governmental benefit plans, supplemental health insurance, limited benefit health insurance, or coverage issued as a supplement to liability.
B. In addition to the powers enumerated in La. Rev. Stat. 22:1206, the plan shall have the authority to assess fees to participating insurers in accordance with the provisions of this Section and to make advance interim fee assessments as may be reasonable and necessary for the plan’s organizational and interim operating expenses. Any interim fees assessed are to be credited as offsets against any regular fees assessed that become payable following the close of the fiscal year.
C. Following the close of each fiscal year, the administrator shall determine the net premiums, premiums less reasonable administrative expense allowances, the plan expenses of administration, and the incurred losses for the year which are attributable to federally defined eligible individuals. The administrator shall take into account investment income and other appropriate gains and losses reasonably attributable to federally defined eligible individuals. Any deficit incurred by the plan shall be identified and recouped as follows:
(1) The board shall identify the source of any deficit related to the provision of coverage to federally defined eligible individuals before assessing any fees authorized under this Section.
(2) The board shall verify the adequacy of any governmental appropriations or alternative funding sources, other than fees assessed under this Section, used to reduce rates for the plan year. Where such funds were not sufficient to support the rate reduction provided, that portion of the deficit reasonably related to the funding shortfalls shall be recouped from any subsequent governmental appropriations or alternative funding sources, other than fees assessed under this Section, prior to making any rate reduction for a subsequent plan year. The board shall take reasonable action to prevent future deficits related to reducing rates based on receipt of government appropriations or alternate funding sources.
(3) The board shall verify the amount of any deficit reasonably resulting from plan losses not attributable to governmental or alternative funding shortfalls used to reduce rates. Any verified deficit amount attributed to federally defined eligible individuals shall be recouped by fees assessed pursuant to this Section to participating insurers.
(4) The board shall provide the commissioner of insurance with a detailed report on any deficit being recouped by fee assessments apportioned pursuant to this Section. The report shall include information on services and utilization patterns which can reasonably be attributed to the deficit as well as analysis and recommendations on cost containment measures which can be taken to minimize future deficits.
(5) The board shall provide the commissioner of insurance with a detailed report on the sources and use of government appropriations and alternate sources of funding used to make rates more affordable. The report shall include information on the activities of similar plans maintained by other states and recommendations for actions that can be taken to make coverage more affordable for plan members.
D.(1) Each participating insurer’s fee assessment shall be in proportion to gross premiums earned on business in this state for policies or contracts covered under this Section for the most recent calendar year for which information is available.
(2) Each participating insurer’s fee assessment shall be determined by the board based on annual statements and other reports deemed to be necessary by the board and filed by the participating insurer with the board. The board may use any reasonable method of estimating the amount of gross premium of a participating insurer if the specific amount is unknown. The plan of operation shall provide the details of the calculation of each participating insurer’s assessment which shall require the approval of the commissioner.
E. A participating insurer may petition the commissioner of insurance for deferral of all or part of any fee assessed by the board. If, in the opinion of the commissioner, payment of the fee assessment would endanger the solvency of the participating insurer, the commissioner may defer, in whole or in part, the fee assessment as part of a voluntary rehabilitation or supervisory plan established to prevent the plan’s insolvency. The duration of any deferral approved under a voluntary rehabilitation or supervisory plan shall be limited to four years. The voluntary rehabilitation or supervisory plan shall require repayment of all deferrals by the end of the period plus legal interest. Until notice of payment in full is received from the board, the insurer shall remain under the voluntary rehabilitation or supervisory plan. In the event a fee assessment against a participating insurer is deferred in whole or in part, the amount by which the fee assessment is deferred may be assessed to the other participating insurers in a manner consistent with the basis for fee assessments set forth in this Section. Collection of deferrals and legal interest shall be used to offset fee assessments against the other participating insurers in a manner consistent with the basis for fee assessments set forth in this Section.
F. This Section shall not be effective until approval of the plan provided for in La. Rev. Stat. 22:1203(E)(2).
Acts 2020, No. 313, §1, eff. June 12, 2020.