Louisiana Revised Statutes 22:976.1 – Fairness in enrollee cost sharing
Terms Used In Louisiana Revised Statutes 22:976.1
- Contract: A legal written agreement that becomes binding when signed.
- 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.
- Partnership: A voluntary contract between two or more persons to pool some or all of their assets into a business, with the agreement that there will be a proportional sharing of profits and losses.
A. As used in this Section the following definitions shall apply:
(1) “Cost-sharing requirement” means any copayment, coinsurance, deductible, or annual limitation on cost-sharing including but not limited to a limitation subject to 42 U.S.C. § 18022(c) and 300gg-6(b), required by or on behalf of an enrollee in order to receive a specific healthcare service, including a prescription drug, covered by a health benefit plan.
(2) “Enrollee” means an individual who is enrolled or insured by a health insurance issuer for healthcare services.
(3) “Health benefit plan” means healthcare services provided directly through insurance, reimbursement, or other means, and including items and services paid for as healthcare services under any hospital or medical service policy or certificate, hospital or medical service plan contract, preferred provider organization contract, or health maintenance organization contract offered by a health insurance issuer.
(4) “Health insurance issuer” means any entity that offers health insurance coverage through a health benefit plan, policy, or certificate of insurance subject to state law that regulates the business of insurance. “Health insurance issuer” includes a health maintenance organization as defined and licensed pursuant to Subpart I of Part I of Chapter 2 of this Title and the office of group benefits as created pursuant to Chapter 12 of Title 42 of the Louisiana Revised Statutes of 1950.
(5) “Healthcare services” means items or services furnished to any individual for the purpose of preventing, alleviating, curing, or healing human illness, injury, or a mental or physical disability.
(6) “Person” means a natural person, corporation, mutual company, unincorporated association, partnership, joint venture, limited liability company, trust, estate, foundation, not-for-profit corporation, unincorporated organization, government or governmental subdivision, or agency.
B. When calculating an enrollee’s contribution to any applicable cost-sharing requirement, a health insurance issuer shall include any cost-sharing amounts paid by the enrollee or on behalf of the enrollee by another person. If application of this requirement results in health savings account ineligibility under 26 U.S.C. § 223, this requirement shall apply for health savings account-qualified high deductible health plans with respect to the deductible of the plan after the enrollee has satisfied the minimum deductible under 26 U.S.C. § 223, except with respect to items or services that are preventive care pursuant to 26 U.S.C. § 223(c)(2)(C), in which case the requirements of this Subsection shall apply regardless of whether the minimum deductible under 26 U.S.C. § 223 has been satisfied.
C. In implementing the requirements of this Section, the state shall regulate a health insurance issuer only to the extent permissible under applicable law.
D. The commissioner of insurance may promulgate rules and regulations in accordance with the Administrative Procedure Act as are necessary to implement this Section.
Acts 2021, No. 431, §1, eff. June 21, 2021; Acts 2022, No. 132, §1, eff. May 26, 2022.