§1061. Definitions
As used in R.S. 22:984 and 1061 through 1079, the following terms shall have the
following meanings:
(1)(a) "Group health plan" means an employee welfare benefit plan as defined in
Section 3(1) of the Employee Retirement Income Security Act of 1974 to the extent that the
plan provides medical care, as defined in Subparagraph (b) of this Paragraph and including
items and services paid for as medical care to employees or their dependents, as defined
under the terms of the plan, directly or through insurance, reimbursement, or otherwise.
(b)"Medical care" means amounts paid for:
(i)The diagnosis, cure, mitigation, treatment, or prevention of disease, or amounts
paid for the purpose of affecting any structure or function of the body.
(ii)Amounts paid for transportation pr
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§1061. Definitions
As used in R.S. 22:984 and 1061 through 1079, the following terms shall have the
following meanings:
(1)(a) "Group health plan" means an employee welfare benefit plan as defined in
Section 3(1) of the Employee Retirement Income Security Act of 1974 to the extent that the
plan provides medical care, as defined in Subparagraph (b) of this Paragraph and including
items and services paid for as medical care to employees or their dependents, as defined
under the terms of the plan, directly or through insurance, reimbursement, or otherwise.
(b) "Medical care" means amounts paid for:
(i) The diagnosis, cure, mitigation, treatment, or prevention of disease, or amounts
paid for the purpose of affecting any structure or function of the body.
(ii) Amounts paid for transportation primarily for and essential to medical care
referred to in Item (i) of this Subparagraph.
(iii) Amounts paid for insurance covering medical care referred to in Items (i) and
(ii) of this Subparagraph.
(c) A program under which creditable coverage described in Paragraph (4) of this
Section is provided shall be treated as a group health plan for purposes of applying R.S.
22:1062(E).
(2) Definitions relating to health insurance are:
(a) "Health insurance coverage" means benefits consisting of medical care, provided
directly, through insurance or reimbursement, or otherwise and including items and services
paid for as medical care, under any hospital or medical service policy or certificate, hospital
or medical service plan contract, preferred provider organization, or health maintenance
organization contract offered by a health insurance issuer.
(b) "Health insurance issuer" means an insurance company, including a health
maintenance organization, as defined and licensed to engage in the business of insurance
under Subpart I of Part I of Chapter 2 of this Title unless preempted as an employee benefit
plan under the Employee Retirement Income Security Act of 1974. Such term does not
include a group health plan.
(c) "Group health insurance coverage" means, in connection with a group health
plan, health insurance coverage offered in connection with such plan.
(d) "Individual health insurance coverage" means health insurance coverage offered
to individuals in the individual market, but does not include short-term limited duration
insurance.
(3) "Excepted benefits" means benefits under one or more of the following:
(a) Benefits not subject to requirements:
(i) Coverage only for accident, or disability income insurance, or any combination.
(ii) Coverage issued as a supplement to liability insurance.
(iii) Liability insurance, including general liability insurance and automobile liability
insurance.
(iv) Workers' compensation or similar insurance.
(v) Automobile medical payment insurance.
(vi) Credit-only insurance.
(vii) Coverage for on-site medical clinics.
(viii) Other similar insurance coverage, specified in regulations issued by the
commissioner of insurance under the Administrative Procedure Act, under which benefits
for medical care are secondary or incidental to other insurance benefits.
(b) Benefits not subject to requirements if offered separately:
(i) Limited scope dental or vision benefits.
(ii) Benefits for long-term care, nursing home care, home health care,
community-based care, or any combination thereof.
(iii) Such other similar, limited benefits as specified in reasonable regulations issued
by the commissioner of insurance.
(c) Benefits not subject to requirements if offered as independent, non-coordinated
benefits:
(i) Coverage only for a specified disease or illness.
(ii) Hospital indemnity or other fixed indemnity insurance.
(d) Benefits not subject to requirements if offered as a separate insurance policy:
(i) Medicare supplemental health insurance as defined under Section 1882(g)(1) of
the Social Security Act.
(ii) Insurance coverage supplemental to military health benefits.
(iii) Similar supplemental coverage provided under a group health plan.
(4) "Creditable coverage" means, with respect to an individual, coverage of the
individual under any of the following:
(a) A group health plan.
(b) Health insurance coverage.
(c) Medicare coverage provided under 42 U.S.C. 1395 et seq.
(d) Medical assistance coverage provided under 42 U.S.C. 1396 et seq.
(e) Medical insurance coverage under the General Military Law.
(f) A medical care program of the Indian Health Service or of a tribal organization.
(g) A state health benefits risk pool.
(h) A health plan offered for federal employees.
(i) A public health plan, as defined in regulations promulgated by the commissioner
of insurance.
(j)(i) A health benefit plan provided to members of the Peace Corps.
(ii) Such term does not include coverage consisting solely of coverage of excepted
benefits, as defined in Paragraph (3) of this Section.
(k) Medical assistance coverage provided under 42 U.S.C. 1397 et seq.
(5) Other definitions are:
(a) "Beneficiary" means a person designated by a participant, or by the terms of a
health insurance benefit plan, who is or may become entitled to a benefit under the plan.
(b) "Bona fide association" means, with respect to health insurance coverage offered
in this state, an association which:
(i) Has been actively in existence for at least five years.
(ii) Has been formed and maintained in good faith for purposes other than obtaining
insurance.
(iii) Does not condition membership in the association on any health status-related
factor relating to an individual, including an employee of an employer or a dependent of an
employee.
(iv) Makes health insurance coverage offered through the association available to all
members regardless of any health status-related factor relating to such members, or
individuals eligible for coverage through a member.
(v) Does not make health insurance coverage offered through the association
available other than in connection with a member of the association.
(vi) Meets such additional requirements as may be imposed by law.
(c) "COBRA continuation provision" means a provision which complies with R.S.
22:1096.
(d) "Employee" means any individual employed by an employer.
(e)(i) "Employer" means any person acting directly as an employer, or indirectly in
the interest of an employer, in relation to an employee benefit plan, and includes a group or
association of employers acting for an employer in such capacity.
(ii) "Large employer" means, in connection with a group health plan with respect to
a calendar year and a plan year, an employer who employed an average of at least fifty-one
employees on business days during the preceding calendar year and who employs at least two
employees on the first day of the plan year.
(iii) "Small employer" means, in connection with a group health plan with respect
to a calendar year and a plan year, an employer who employed an average of at least one but
not more than fifty employees on business days during the preceding calendar year and who
employs at least one employee on the first day of the plan year.
(iv) For purposes of this Subparagraph the following persons shall be treated as one
employer:
(aa) Corporations which are members of a controlled group of corporations.
(bb) Trades or businesses, whether or not incorporated, which are under common
control.
(cc) Affiliated service groups.
(v) In the case of an employer which was not in existence throughout the preceding
calendar year, the determination of whether such employer is a small or large employer shall
be based on the average number of employees that is reasonably expected such employer will
employ on business days in the current calendar year.
(vi) Any reference in this Subparagraph to an employer shall include a reference to
any predecessor of such employer.
(vii) At the option of a health insurance issuer, the health insurance issuer may
require that a majority of the employees covered under an employee benefit plan are
employed or reside in this state, and that there is a bona fide employer-employee relationship
to prevent the formation of employer groups primarily for the purposes of buying health
insurance.
(f) "Church plan" means a plan established and maintained for its employees or their
beneficiaries by a church, convention, or association of churches. A plan established and
maintained for its employees or their beneficiaries by a church, convention, or association
of churches includes a plan maintained by an organization, whether a civil law corporation
or otherwise, the principal purpose or function of which is the administration or funding of
a plan or program for the provision of retirement benefits or welfare benefits, or both, for the
employees of a church, convention, or association of churches, if such organization is
controlled by or associated with a church, convention, or association of churches. The term
"church plan" does not include a plan which is established and maintained primarily for the
benefit of employees or their beneficiaries of such church, convention, or association of
churches who are employed in connection with one or more unrelated trades or businesses.
(g)(i) "Governmental plan" means a plan established or maintained for its employees
by the government of the United States, by the government of any state or political
subdivision thereof, or by any agency or instrumentality of any of the foregoing.
(ii) "Federal governmental plan" means a governmental plan established or
maintained for its employees by the government of the United States or by any agency or
instrumentality of such government.
(iii) "Nonfederal governmental plan" means a governmental plan that is not a federal
governmental plan.
(h) "Health status-related factor" means any of the factors described under R.S.
22:1063(A)(1).
(i) "Network plan" means health insurance coverage of a health insurance issuer
under which the financing and delivery of medical care, including items and services paid
for as medical care, are provided, in whole or in part, through a defined set of providers
under contract or other participation agreement with the issuer.
(j) "Participant" means any employee or former employee of an employer, or any
member or former member of an employee organization, who is or may become eligible to
receive a benefit of any type from an employee benefit plan which covers employees of such
employer or members of such organization, or whose beneficiaries may be eligible to receive
any such benefit.
(k) "Placement" or "being placed", for adoption, in connection with any placement
for adoption of a child with any person, means the assumption and retention by such person
of a legal obligation for total or partial support of such child in anticipation of adoption of
such child. The child's placement with such person terminates upon the termination of such
legal obligation.
(l) "Plan sponsor" means:
(i) The employer in the case of a health benefit plan established or maintained by a
single employer.
(ii) The employee organization in the case of a plan established or maintained by an
employee organization.
(iii) In the case of a plan established or maintained by two or more employers or
jointly by one or more employers and one or more employee organizations, the association,
committee, joint board of trustees, or other similar group or representatives of the parties
who establish or maintain the plan.
(m) "Individual market" means the market for health insurance coverage offered to
individuals other than in connection with a group health plan, and includes coverage offered
in connection with a group health plan that has fewer than two participants as current
employees on the first day of the plan year.
(n) "Large group market" means the health insurance market under which individuals
obtain health insurance coverage, directly or through any arrangement, on behalf of
themselves and their dependents through a group health plan maintained by a large employer.
(o) "Small group market" means the health insurance market under which individuals
obtain health insurance coverage, directly or through any arrangement, on behalf of
themselves, and their dependents, through a group health plan maintained by a small
employer.
(p) "Preexisting condition exclusion" means, with respect to coverage, a limitation
or exclusion of benefits relating to a condition based on the fact that the condition was
present before the date of enrollment for such coverage, whether or not any medical advice,
diagnosis, care, or treatment was recommended or received before such date. Genetic
information shall not be treated as a preexisting condition in the absence of a diagnosis of
the condition related to such information.
(q) "Enrollment date" means, with respect to an individual covered under a group
health plan or health insurance coverage, the date of enrollment of the individual in the plan
or coverage or, if earlier, the first day of the waiting period for such enrollment.
(r) "Late enrollee" means, with respect to coverage under a group health plan, a
participant or beneficiary who enrolls under the plan other than during:
(i) The first period in which the individual is eligible to enroll under the plan.
(ii) A special enrollment period under R.S. 22:1062(F).
(s) "Waiting period" means, with respect to a group health plan and an individual
who is a potential participant or beneficiary in the plan, the period that must pass with respect
to the individual before the individual is eligible to be covered for benefits under the terms
of the plan.
(t) "Affiliation period" means a period which, under the terms of the health insurance
coverage offered by the health maintenance organization, must expire before the health
insurance coverage becomes effective. The organization is not required to provide health
care services or benefits during such period and no premium shall be charged to the
participant or beneficiary for any coverage during the period.
(u) "Affiliated service group" means a group consisting of a service organization,
hereinafter in this Paragraph referred to as the "first organization", and one or more of the
following:
(i) Any service organization which:
(aa) Is a shareholder or partner in the first organization.
(bb) Regularly performs services for the first organization or is regularly associated
with the first organization in performing services for third persons.
(ii) Any other organization if:
(aa) A significant portion of the business of such organization is the performance of
services of a type historically performed in such service field by employees.
(bb) Ten percent or more of the interests in such organization is held by persons who
are highly compensated employees of the first organization or an organization described in
Item (i) of this Subparagraph.
(v) "Service organization" means an organization the principal business of which is
the performance of services.
(w) "Individual policy" means an accident and health insurance policy or certificate
delivered or issued for delivery in this state by an insurer, nonprofit hospital or medical
service organization, a domestic nonprofit mutual association which is engaged in the
furnishing of hospital services, medical or surgical benefits, a health maintenance
organization, or a self-insurance plan.
(x) "Portability" shall mean the exemption of the standard preexisting condition
under a subsequent health insurance policy following the termination of a policy or plan from
a previous health insurance policy or plan.
(y) "Modification affecting drug coverage" means any of the following:
(i) Removing a drug from a formulary.
(ii) Adding a requirement that an enrollee receive prior authorization for a drug.
(iii) Imposing or altering a quantity limit for a drug.
(iv) Imposing a step-therapy restriction for a drug.
(v) Moving a drug to a higher cost-sharing tier, unless a generic alternative is
available.
NOTE: Former R.S. 22:1061 redesignated as R.S. 22:838 by Acts 2008, No.
415, §1, eff. Jan. 1, 2009.