A. Any natural person who has been domiciled in this state for six consecutive months shall be eligible for coverage as a nonfederally defined individual as provided in this Subpart, except the following:
(1)Any person who, on the effective date of coverage by the plan or at any time thereafter, is eligible for coverage under health and accident insurance offered by an insurer, reinsurer, or insurance arrangement. A person shall be considered eligible for coverage by an insurer or insurance arrangement as described herein if he meets the criteria for eligibility under any group health benefits plan provided by his employer, union, or other organization of which he is a member, whether or not the person actually is covered under such plan.
(2)Any person who is, at the time of application
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A. Any natural person who has been domiciled in this state for six consecutive months shall be eligible for coverage as a nonfederally defined individual as provided in this Subpart, except the following:
(1) Any person who, on the effective date of coverage by the plan or at any time thereafter, is eligible for coverage under health and accident insurance offered by an insurer, reinsurer, or insurance arrangement. A person shall be considered eligible for coverage by an insurer or insurance arrangement as described herein if he meets the criteria for eligibility under any group health benefits plan provided by his employer, union, or other organization of which he is a member, whether or not the person actually is covered under such plan.
(2) Any person who is, at the time of application for coverage by the plan, eligible for health benefits under Medicaid or Medicare as defined in R.S. 22:1202.
(3) Any person whose coverage by the plan was terminated for nonpayment of premiums unless twelve months have lapsed since such termination.
(4) Any person on whose behalf the plan has paid out the maximum lifetime benefits under the benefits plan as may be established by the plan.
(5) Inmates of public institutions.
(6) Persons eligible for public programs as defined in R.S. 22:1202.
(7) Persons who are not domiciled in this state.
B.(1) Any federally defined eligible individual who is and continues to be a resident of this state shall be eligible for plan coverage as an individual or family group. Each dependent of a person who is eligible for plan coverage shall also be eligible for plan coverage.
(2) Any person meeting any and all eligibility requirements under any approved federal waiver shall be eligible for plan coverage, provided all other eligibility criteria for plan coverage as a federally defined eligible individual are met.
C. Any person who ceases to meet the eligibility requirements of this Section may be terminated from coverage by the plan at the time of loss of eligibility, but any unearned premium shall be refunded. However, this Subsection shall not apply to any person receiving cancer treatment or cancer therapy or any person with an immune system disorder requiring immunosuppression drug treatment or maintenance not covered by Medicaid or Medicare unless such person is eligible for or has attained Medicare at age sixty-five or older.
D.(1) Nonfederally defined eligible individuals whose health and accident insurance coverage has been involuntarily terminated may apply for coverage under the plan. If such coverage is applied for within sixty-three days after the involuntary termination and if premiums assessed by the plan are paid for the entire coverage period, the effective date of the coverage by the plan shall be the date of termination of the previous coverage.
(2) Any person meeting any and all eligibility requirements under any approved federal waiver shall be eligible for plan coverage, provided all other eligibility criteria for plan coverage as a nonfederally defined eligible individual are met.
E. Any natural person who changes his domicile to this state and who at the time domicile is established in this state is insured by the health insurance plan or similar organization for his former domiciliary state shall be eligible for coverage by the plan if:
(1) The health insurance plan or similar organization of the former domiciliary state provides coverage similar to that offered by the plan.
(2) The health insurance plan or similar organization of the former domiciliary state certifies, on a form acceptable to the plan, that the person seeking coverage by the plan is currently insured in such other state.
(3) The commissioner determines that the law of the former domiciliary state provides similar coverage to Louisianians insured by the plan upon their establishment of domicile in such other state.
F.(1) Notwithstanding the provisions of Paragraph (A)(1) of this Section, upon certification by an independent actuarial firm that funds of the plan are sufficient to support the enrollment of additional persons, the board may authorize the enrollment of additional persons as provided for in this Subsection. Any person whose individual insurance premium rate for comparable coverage exceeds by more than two hundred percent the maximum rate which the plan may be authorized to charge under R.S. 22:1213(F)(3), for persons of comparable age, sex, and geographical location, shall be eligible for coverage as provided in this Subpart.
(2) As used in this Subsection, the term "eligible" shall not include persons whose employer, union, or other organization provides a group health benefits plan through an insurer or insurance arrangement to its employees or members, or their dependents, and such person is eligible for coverage under such group health benefits plan.
(3) Plan coverage for which a person is eligible under this Subsection shall exclude charges or expenses incurred or caused by preexisting conditions, as provided in R.S. 22:1213(G).
(4) The board shall establish policies and procedures to effectuate the provisions of this Subsection, which policies and procedures shall:
(a) Guarantee uninterrupted enrollment of federally defined eligible individuals.
(b) Give preference to the applications for membership of persons who, at the time of application, are uninsured and uninsurable, and satisfy the eligibility requirements of Subsection A of this Section.
(5)(a) It shall constitute an unfair trade practice under the provisions of R.S. 22:1961 et seq., for any insurer, reinsurer, insurance agent or broker, or employer, to refer an individual employee to the plan, or to arrange for an individual employee to apply to the program, for the purpose of separating such employee from a group health benefits plan provided in connection with the employee's employment.
(b) In the event that an individual receives coverage by the plan in contravention of this Subsection, the plan may terminate the coverage of the individual but shall maintain a cause of action against any offender of this Subsection for a total amount not less than double the amount of any or all claims paid on behalf of the individual whenever made, without limitation, plus ten thousand dollars for each incident, and attorney fees, court costs, and interest from date of demand by the plan.
NOTE: Former R.S. 22:1207 redesignated as R.S. 22:1627 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.