§2243. Small employer and individual insurance program criteria

Any small employer or individual insurance program developed shall include but not be limited to the following features:

(1) Eligibility criteria for small employers that may include limiting participation to those employers who have not offered group health insurance coverage to their employees for at least two years or such shorter period as may be permitted by regulation promulgated by the commissioner of insurance. Any pilot program involving a public subsidy towards the purchase of policies or contracts of coverage will have additional eligibility criteria established by the Louisiana Department of Health for participation of health insurance issuers.

(2) Eligibility criteria that limit participation to health insurance issuers who have not been found to be financially impaired by the department in the preceding two years. For purposes of this Section, the term "health insurance issuer" shall mean an insurance company, including a health maintenance organization as defined and licensed pursuant to Subpart I of Part I of Chapter 2 of this Title, R.S. 22:241 et seq.

(3) Participation criteria that limits the number of policies or contracts of coverage that a participating health insurance issuer may issue under the program to twenty percent of the health insurance issuer's other commercial coverage that meets the requirements of R.S. 22:984, and 1061 through 1079.

(4) Benefit criteria that require participating health insurance issuers to offer group and individual health insurance as defined in R.S. 22:1061(2).

(5) Health insurance criteria for health insurers that define the coverage that may be marketed under the program. Notwithstanding any law to the contrary, small employer group insurance approved for marketing under the program shall be required to meet the requirements of R.S. 22:984, and 1061 through 1079.

(6) Underwriting criteria that establish standards for normal insurance risk associated with individuals covered under a pilot program. Such criteria shall include underwriting standards based on each health insurance issuer's group and individual insurance products approved for marketing under a pilot program.

(7) Risk criteria for payment of losses resulting from individuals whose medical conditions do not meet the standards for normal group or individual insurance risk established pursuant to Paragraph (6) of this Section. The risk criteria established shall utilize medical loss data, compendium data, or an actuarial certification of the loss determination method by an actuary certified by the American Academy of Actuaries in Health Insurance.

(8) Employer participation requirements that provide for payment of at least fifty percent of the eligible employee premium cost or twenty-five percent of the premium cost for all persons covered under the group benefit plan.

(9) Participation requirements that may provide for a minimum number of eligible employees to be covered by the plan. Such requirements shall not require participation of more than seventy-five percent of all eligible employees or sixty percent of those eligible employees who do not have other creditable coverage or fifty percent of those eligible employees who do not have creditable coverage with carriers other than the participating carrier.

(10) Criteria for providing a public subsidy towards the purchase of policies or contracts of coverage.

(11) Provider payment requirements for participating health insurers.

Acts 1993, No. 660, §1; Acts 1995, No. 593, §1; Acts 1997, No. 974, §1; Acts 1999, No. 294, §1; Acts 2003, No. 424, §1, eff. June 18, 2003; Acts 2004, No. 751, §1; Redesignated from R.S. 22:246 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009; Acts 2012, No. 271, §1.