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Regular Session, 2010 ENROLLED
SENATE BILL NO. 153
BY SENATOR ERDEY
AN ACT1
To amend and reenact R.S. 22:1061(3)(d)(i), 1073(B)(4), 1210(D) and (E), and 1213, to2
enact R.S. 22:1061(4)(k) and 1205(C)(6), and to repeal R.S. 22:1210(F), relative to3
the Louisiana Health Plan; to provide for compliance with federal law for expanded4
coverage by the plan; to redefine certain terms relative to portability, availability,5
and renewability of health insurance coverage; to provide with respect to coverage6
of mental and nervous conditions, including alcohol and substance abuse, by the7
plan; to provide with respect to initial rates for federally and non-federally defined8
eligible individuals; to delete the six-month preexisting condition provision for9
federally defined eligible individuals; and to provide for related matters.10
Be it enacted by the Legislature of Louisiana:11
Section 1. R.S. 22:1061(3)(d)(i), 1073(B)(4), 1210(D), and (E), 1213 are hereby12
amended and reenacted and R.S. 22:1061(4)(k) and 1205(C)(6) are hereby enacted to read13
as follows:14
§1061. Definitions15
As used in R.S. 22:984 and 1061 through 1079, the following terms shall16
have the following meanings:17
* * *18
(3) "Excepted benefits" means benefits under one or more of the following:19
* * *20
(d) Benefits not subject to requirements if offered as a separate insurance21
policy:22
(i) Medicare coverage. supplemental health insurance as defined under23
Section 1882(g)(1) of the Social Security Act.24
* * *25
(4) "Creditable coverage" means, with respect to an individual, coverage of26
the individual under any of the following:27
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* * *1
(k) Medical assistance coverage provided under 42 USCA 1397 et seq.2
* * *3
§1073. Guaranteed availability of individual health insurance coverage to certain4
individuals with prior group or individual coverage5
* * *6
B. As used in this Section, the term "eligible individual" means an individual7
who meets the requirements of Subsection H of this Section or an individual:8
* * *9
(4) Who, elected if offered the option of continuation of coverage under10
a COBRA continuation provision or under a similar state program., elected this11
coverage.12
* * *13
§1205. Plan of operation14
* * *15
C. In its plan of operation the board shall:16
* * *17
(6) Provide the details of the calculation of each participating insurer's18
assessment.19
* * *20
§1210. Fees assessed to participating health insurers for plan losses attributable to21
federally defined eligible individuals22
* * *23
D.(1) Each participating insurer's fee assessment shall be in the proportion24
to gross premiums earned on business in this state for policies or contracts covered25
under this Section for the most recent calendar year for which information is26
available.27
E. (2) Each participating insurer's fee assessment shall be determined by the28
board based on annual statements and other reports deemed to be necessary by the29
board and filed by the participating insurer with the board. The board may use any30 SB NO. 153 ENROLLED
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reasonable method of estimating the amount of gross premium of a participating1
insurer if the specific amount is unknown. The plan of operation shall provide the2
details of the calculation of each participating insurer's assessment which shall3
require the approval of the commissioner.4
F. E. A participating insurer may petition the commissioner of insurance for5
deferral of all or part of any fee assessed by the board. If, in the opinion of the6
commissioner, payment of the fee assessment would endanger the solvency of the7
participating insurer, the commissioner may defer, in whole or in part, the fee8
assessment as part of a voluntary rehabilitation or supervisory plan established to9
prevent the plan's insolvency. Any deferrals approved under a voluntary10
rehabilitation or supervisory plan shall be limited to four years and require11
repayment of all deferrals by the end of such period plus legal interest. Until notice12
of payment in full is received from the board, the insurer shall remain under the13
voluntary rehabilitation or supervisory plan. In the event a fee assessment against14
a participating insurer is deferred in whole or in part, the amount by which the fee15
assessment is deferred may be assessed to the other participating insurers in a16
manner consistent with the basis for fee assessments set forth in this Section.17
Collection of such deferrals and legal interest shall be used to offset fee assessments18
against the other participating insurers in a manner consistent with the basis for fee19
assessments set forth in this Section.20
* * *21
§1213. Benefits; availability22
A. The plan shall offer comprehensive coverage to every eligible person who23
is not eligible for Medicare and public programs as defined in this Subpart.24
Comprehensive coverage offered by the plan shall pay an eligible person's covered25
expenses, subject to limits on the deductible and coinsurance payments authorized26
under Paragraph (4) of Subsection F E of this Section, up to a maximum lifetime27
benefit as established by the board of not less than five hundred thousand dollars per28
covered person, payable up to a maximum of two hundred fifty thousand dollars per29
covered person per twelve consecutive months of coverage. For federally defined30 SB NO. 153 ENROLLED
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eligible persons, the board shall establish benefits and maximum benefit amounts in1
accordance with applicable federal law and regulations.2
B. The board shall establish reasonable reimbursement amounts for the3
following services and articles prescribed by a health care provider and determined4
by the plan to be medically necessary, including but not limited to: Covered5
expenses shall be the usual, customary, and reasonable charge, as established6
by the board, in the locality for the following services and articles when7
prescribed by a physician and determined by the plan to be medically necessary8
for the following areas of services:9
(1) Hospital services.10
(2) Professional services for the diagnosis or treatment of injuries, illnesses,11
or conditions which are rendered by a health care provider or by other licensed12
professionals at the direction of a health care provider.13
(3) Services of a licensed skilled nursing facility for up to a maximum of one14
hundred twenty days per twelve consecutive months of coverage, unless extended15
for additional days under any cost containment program implemented by the board16
pursuant to Subsection I H of this Section.17
(4) Services of a home health agency up to a maximum of two hundred18
seventy services per twelve consecutive months of coverage, unless increased under19
any cost containment program implemented by the board pursuant to Subsection I20
H of this Section.21
(5) Use of radium or other radioactive materials.22
(6) Oxygen.23
(7) Anesthetics.24
(8) Prostheses other than dental.25
(9) Rental of durable medical equipment, other than eyeglasses and hearing26
aids, for which there is no personal use in the absence of the conditions for which it27
is prescribed.28
(10) Diagnostic X-rays and laboratory tests.29
(11) Oral surgery for excision of partially or completely unerupted, impacted30 SB NO. 153 ENROLLED
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teeth or the gums and tissues of the mouth when not performed in connection with1
the extraction or repair of other teeth.2
(12) Services of a physical therapist.3
(13) Transportation provided by a licensed ambulance service to the nearest4
facility qualified to treat the condition.5
(14) Services for diagnosis and treatment of mental and nervous6
disorders provided that a covered person may be required to pay up to a fifty7
percent coinsurance payment, and the plan's payment may not exceed twenty-8
five thousand dollars. Notwithstanding the previous provision, the department9
may conduct a periodic actuarial cost analysis to determine whether the plan's10
maximum payment for outpatient services for diagnosis and treatment of11
mental and nervous disorders should be adjusted.12
C. The board shall establish reasonable reimbursement amounts for any13
services covered under the benefits plans which are not included in Subsection B of14
this Section.15
D. In the event the amounts charged for services and articles provided by or16
at the direction of a health care provider exceed the amount payable for covered17
expenses as provided herein, the health care provider may seek payment of the18
balance owed from the member as allowed under applicable contracts or state and19
federal laws and regulations.20
E. Covered expenses shall not include the following, except as mandated by21
applicable federal law for federally defined eligible individuals:22
(1) Any charge for treatment for cosmetic purposes other than surgery for the23
repair or treatment of an injury or a congenital bodily defect to restore normal bodily24
functions.25
(2) Care which is primarily for custodial purposes.26
(3) Any charge for confinement in a private room to the extent surcharge is27
in excess of the institution's charge for its most common semiprivate room, unless28
a private room is prescribed as medically necessary by a physician.29
(4) That part of any charge for services rendered or articles prescribed by a30 SB NO. 153 ENROLLED
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physician, dentist, or other health care provider which exceeds the reasonable1
reimbursement amounts established in Subsections B and C of this Section or for any2
charge not medically necessary.3
(5) Any charge for services or articles the provision of which is not within the4
scope of authorized practice of the institution or individual providing the services or5
articles.6
(6) Any expense incurred prior to the effective date of coverage by the plan7
for the person on whose behalf the expense is incurred.8
(7) Dental care except as provided in Subsection B of this Section.9
(8) Eyeglasses and hearing aids.10
(9) Illness or injury due to acts of war.11
(10) Services of blood donors and any fee for failure to replace the first three12
pints of blood provided to an eligible person each policy year.13
(11) Personal supplies or personal services provided by a hospital or nursing14
home, or any other nonmedical or nonprescribed supply or service.15
(12) Any charge for the diagnosis and treatment of mental and nervous16
disorders, including alcohol and substance abuse.17
F. E.(1) Premiums charged for coverages issued by the plan may not be18
unreasonable in relation to the benefits provided, the risk experience, and the19
reasonable expenses of providing the coverage.20
(2) Separate schedules of premium rates based on age, sex, and geographical21
location may apply for individual risks. Separate schedules of premium rates for22
federally defined eligible individuals may be based on age, sex, and geographical23
location, in accordance with applicable federal laws and regulations.24
(3)(a) The plan, with the assistance of the commissioner, shall determine25
the standard risk rate by calculating the average individual standard rate charged by26
the five largest insurers offering coverages in the state comparable to the plan27
coverage. In the event five insurers do not offer comparable coverage, the standard28
risk rate shall be established using reasonable actuarial techniques and shall reflect29
anticipated experience and expenses for such coverage.30 SB NO. 153 ENROLLED
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(b) Standard risk rates for federally defined eligibles eligible individuals1
shall comply with all applicable federal laws and regulations. Initial rates for plan2
coverage for federally defined eligible individuals shall not be less than one3
hundred twenty-five percent of rates established as applicable for individual4
standard risks. In no event shall plan rates exceed two hundred percent of rates5
applicable to the individual standard risks.6
(c) Initial rates for plan coverage provided to nonfederally defined eligible7
individuals shall not be less than one hundred fifty percent of rates established as8
applicable for individual standard risks, or the minimum monthly rates as provided9
for herein, whichever is greater. Subsequent rates provided to nonfederally defined10
eligible individuals shall be established to provide fully for the expected costs of11
claims, including recovery of prior losses, expenses of operation, investment income12
of claim reserves, and any other cost factors subject to the limitations described13
herein. In no event shall plan rates exceed two hundred percent of rates applicable14
to individual standard risks. In no event shall rates be lower than one hundred ten15
percent of rates applicable to individual standard risks.16
(4) The plan coverage defined in this Section shall provide benefits,17
deductibles, coinsurance, and copayments to be established by the board. In addition,18
the board may establish optional benefits, deductibles, coinsurance, and copayments.19
G F. Plan coverage provided to non-federally defined eligible individuals20
shall exclude charges or expenses incurred for or caused by preexisting conditions21
as allowed under R.S. 22:1073(A)(1)(b)., except that no preexisting condition22
exclusion shall be applied to a federally defined eligible individual.23
H. G. (1) Notwithstanding any other law to the contrary, the coverage24
provided by the plan shall be considered excess coverage, and benefits otherwise25
payable under plan coverage shall be reduced by all hospital and medical expense26
benefits paid or payable under any workers' compensation coverage, automobile27
medical payment, or liability insurance whether provided on the basis of fault or28
nonfault, and by any hospital or medical benefits paid or payable by any insurer or29
insurance arrangement or any hospital or medical benefits paid or payable under or30 SB NO. 153 ENROLLED
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provided pursuant to any state or federal law or program.1
(2) The plan shall have a cause of action against an eligible person for the2
recovery of the amount of benefits paid by it which are not covered expenses.3
Benefits due from the plan may be reduced or refused as a set-off against any amount4
recoverable under this Paragraph.5
I. H. The benefits plan offered pursuant to this Section shall include such6
managed care provisions as the board deems necessary and proper for:7
(1) Compliance with applicable federal laws and regulations regarding8
choices of benefit coverage for federally defined eligible individuals.9
(2) Containment of costs, including precertification and concurrent or10
continued stay review of hospital admissions, mandatory outpatient surgical11
procedures, preadmission testing, or any other provisions determined by the board12
to be cost effective and consistent with the purposes of this Subpart.13
J. I. Except as otherwise provided in this Subpart and in R.S. 22:976, this14
Section shall establish the exclusive means for determining the benefits required to15
be offered by the plan, notwithstanding any mandatory benefits or required policy16
provisions in this Title to the contrary.17
Section 2. R.S. 22:1210(F) is hereby repealed.18
Section 3. This Act shall become effective upon signature by the governor or, if not19
signed by the governor, upon expiration of the time for bills to become law without signature20
by the governor, as provided by Article III, Section 18 of the Constitution of Louisiana. If21
vetoed by the governor and subsequently approved by the legislature, this Act shall become22
effective on the day following such approval.23
PRESIDENT OF THE SENATE
SPEAKER OF THE HOUSE OF REPRESENTATIVES
GOVERNOR OF THE STATE OF LOUISIANA
APPROVED: