§1068. Guaranteed renewability of coverage for employers in the group market
A. Except as provided in this Section, if a health insurance issuer offers health
insurance coverage in the small or large group market in connection with a group health plan,
the issuer must renew or continue in force such coverage at the option of the plan sponsor
of the plan.
B. A health insurance issuer may non-renew or discontinue health insurance
coverage offered in connection with a group health plan in the small or large group market
based only on one or more of the following:
(1)The plan sponsor has failed to pay premiums or contributions in accordance with
the terms of the health insurance coverage or the issuer has not received timely premium
payments.
(2)The plan sponsor has performed an act or pract
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§1068. Guaranteed renewability of coverage for employers in the group market
A. Except as provided in this Section, if a health insurance issuer offers health
insurance coverage in the small or large group market in connection with a group health plan,
the issuer must renew or continue in force such coverage at the option of the plan sponsor
of the plan.
B. A health insurance issuer may non-renew or discontinue health insurance
coverage offered in connection with a group health plan in the small or large group market
based only on one or more of the following:
(1) The plan sponsor has failed to pay premiums or contributions in accordance with
the terms of the health insurance coverage or the issuer has not received timely premium
payments.
(2) The plan sponsor has performed an act or practice that constitutes fraud or made
an intentional misrepresentation of material fact. Such health insurance coverage may not be
cancelled except with prior notice to the enrollee or insured, and shall comply with any
applicable federal law or regulation. The provisions of this Paragraph shall not apply to
limited benefit health insurance policies or contracts authorized to be issued in this state.The
provisions of this Subsection shall not apply to limited benefit health insurance policies or
contracts, disability income, long-term care, nursing home care, home health care,
community based care, dental or vision benefits, Medicare supplement, specified disease or
illness, hospital indemnity or other fixed indemnity insurance, workers' compensation or
similar insurance.
(3) The plan sponsor has failed to comply with a material plan provision relating to
employer contribution or group participation rules, as permitted under R.S. 22:1067(D) in
the case of the small group market or pursuant to applicable state law in the case of the large
group market.
(4) The issuer is ceasing to offer coverage in such market in accordance with
Subsection C of this Section and applicable state law.
(5) In the case of a health insurance issuer that offers health insurance coverage in
the market through a network plan, there is no longer any enrollee in connection with such
plan who lives, resides, or works in the service area of the issuer, or in the area for which the
issuer is authorized to do business, and, in the case of the small group market, the issuer
would deny enrollment with respect to such plan under R.S. 22:1067(B)(1)(a).
(6) In the case of health insurance coverage that is made available in the small or
large group market, as the case may be, only through one or more bona fide associations, the
membership of an employer in the association, on the basis of which the coverage is
provided, ceases but only if such coverage is terminated under this Paragraph uniformly
without regard to any health status-related factor relating to any covered individual.
C.(1) In any case in which an issuer decides to discontinue offering a particular type
of group health insurance coverage offered in the small or large group market, coverage of
such type may be discontinued by the issuer in such market only if:
(a) The issuer provides notice to each plan sponsor provided coverage of this type
in such market, and participants and beneficiaries covered under such coverage, of such
discontinuation at least ninety days prior to the date of the discontinuation of such coverage.
(b) The issuer offers to each plan sponsor provided coverage of this type in such
market, the option to purchase all, or, in the case of the large group market, any other health
insurance coverage currently being offered by the issuer to a group health plan in such
market.
(c) In exercising the option to discontinue coverage of this type and in offering the
option of coverage under Subparagraph (b) of this Paragraph, the issuer acts uniformly
without regard to the claims experience of those sponsors or any health status-related factor
relating to any participants or beneficiaries covered or new participants or beneficiaries who
may become eligible for such coverage.
(d) Prior to providing the notice required by Subparagraph (a) of this Paragraph, the
issuer files such notice and the insurance product being discontinued with the commissioner
of insurance.
(2)(a) In any case in which a health insurance issuer elects to discontinue offering
all health insurance coverage in the small group market or the large group market, or both
markets, in the state, health insurance coverage may be discontinued by the issuer if:
(i) The issuer provides notice to the commissioner of insurance and to each plan
sponsor, and participants and beneficiaries covered under such coverage, of such
discontinuation at least one hundred eighty days prior to the date of the discontinuation of
such coverage.
(ii) All health insurance issued or delivered for issuance in this state in such market
or markets is discontinued and coverage under such health insurance coverage in such market
or markets is not renewed.
(iii) Prior to providing the notice required by Item (i) of this Subparagraph, the issuer
files with the commissioner of insurance the notice and the insurance product being
discontinued for certification that the notice is in compliance with this Section. Notice shall
not be issued to the insureds or enrollees until the expiration of twenty days after the notice
and insurance product being discontinued have been filed unless the commissioner of
insurance gives his written approval prior to that time.
(b) In the case of a discontinuation in the small group market or large group market
under Subparagraph (a) of this Paragraph, any plan sponsor's policy or coverage that is not
subject to renewal during the minimum one-hundred-eighty-day notice period shall remain
in force until the termination date upon which the contracted period of coverage ends. Any
plan sponsor's policy or coverage whose renewal date falls within the minimum one-hundred-eighty-day notice period shall remain in force for one hundred eighty days from the date that
the notice of discontinuation was issued.
(c) In the case of a discontinuation under Subparagraph (a) of this Paragraph in a
market, the issuer may not provide for the issuance of any health insurance coverage in the
market and state during the five-year period beginning on the date of the discontinuation of
the last health insurance coverage not so renewed.
(3) No health insurance issuer shall not renew any policy or contract of coverage in
the small or large group market prior to the end of the last period of coverage as stated in
such policy or contract.
D. A health insurance issuer may modify health insurance coverage offered to a
group health plan if each of the following conditions is met:
(1) The modification occurs at the time of coverage renewal.
(2) The modification is approved by the commissioner and is effective on a uniform
basis among all small or large employers covered by that group health plan. However, for
purposes of this Section, modifications affecting drug coverage shall not require approval by
the commissioner.
(3) The issuer notifies, on a form approved by the Department of Insurance, each
affected covered small or large employer and enrollee of the modification, including
modification of coverage of a particular product or modification of drug coverage, not later
than the sixtieth day before the date the modification is effective. Notwithstanding the
requirements of Paragraph (1) of this Subsection, modification of drug coverage for any drug
increasing over three hundred dollars per prescription or refill with an increase in the
wholesale acquisition cost of at least twenty-five percent in the prior three hundred sixty-five
days may occur at any time provided that thirty-day notice of the modification of coverage
is given. The thirty-day notice of modification of coverage shall include information on the
issuer's process for an enrollee's physician to request an exception from the issuer's
modification of drug coverage for purposes of continuity of care of the patient.
E. In applying this Section in the case of health insurance coverage that is made
available by a health insurance issuer in the small or large group market to employers only
through one or more associations, a reference to "plan sponsor" is deemed, with respect to
coverage provided to an employer member of the association, to include a reference to such
employer.
F. The Department of Insurance shall have the authority, pursuant to the
Administrative Procedure Act, to promulgate and adopt rules and regulations necessary to
implement the provisions of this Section.
NOTE: Former R.S. 22:1068 redesignated as R.S. 22:832 by Acts 2008, No.
415, §1, eff. Jan. 1, 2009.