§1095. Rating factors; risk pools; individual market plan and calendar year requirement

A. Health insurance issuers may vary premiums from the plan-adjusted index rate in the individual or small group market due only to one or more of the following factors:

(1) The number of persons such product or coverage covers, whether an individual or family.

(2) Geographic rating area, as established in accordance with this Section.

(3) Age, except that such variation shall be no more than three-to-one for adults.

(4) Tobacco use as defined in 45 C.F.R. 147.102 or any subsequent federal law, except that such rate shall not vary by more than one- and one-half-to-one.

B. Every health insurance issuer in this state shall maintain a single, separate, and distinct risk pool for the individual market and a single, separate, and distinct risk pool for the small group market. Health insurance issuers of student health plans shall maintain a single, separate, and distinct risk pool for student health plans.

C. To the extent that they are applied to coverage issued to members within a family under a small group plan, the ratings variations permitted under Paragraphs (A)(3) and (4) of this Section shall be attributed to each member to whom those factors apply and the factors may be applied only as permitted by federal law.

D. Consistent with the single risk pool requirement, as of January 1, 2015, all nongrandfathered coverage in the individual market shall be offered on a calendar year basis. For purposes of new enrollment effective on any date other than January first, the first policy year following such enrollment may comprise a prorated policy year, ending on December thirty-first. Any exceptions or modifications to the calendar year requirement by federal law or rule shall also apply to health insurance issuers under this Section.

E. The department shall determine the geographic rating area or areas in this state by rule, regulation, bulletin, or any other mechanism made available by law.

F. Any rate proposed to be used by a health insurance issuer shall be submitted and controlled by this Subpart. However, the commissioner shall have the authority to grant transitional relief from the provisions of this Subpart.

Acts 1993, No. 655, §1; Acts 1995, No. 593, §1; Acts 1995, No. 1173, §1; Acts 1997, No. 1165, §1; Acts 2001, No. 272, §1, eff. Jan. 1, 2002; Acts 2004, No. 426, §1; Redesignated from R.S. 22:228.6 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009; Acts 2010, No. 919, §1, eff. Jan. 1, 2011; Acts 2014, No. 718, §1, eff. June 18, 2014.