A.The plan shall offer comprehensive coverage to every eligible person who is not eligible for Medicare and public programs as defined in this Subpart. Comprehensive coverage offered by the plan shall pay an eligible person's covered expenses, subject to limits on the deductible and coinsurance payments authorized under Paragraph (4) of Subsection E of this Section, up to a maximum lifetime benefit as established by the board of not less than five hundred thousand dollars per covered person, payable up to a maximum of two hundred fifty thousand dollars per covered person per twelve consecutive months of coverage. For federally defined eligible persons, the board shall establish benefits and maximum benefit amounts in accordance with applicable federal law and regulations.
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A. The plan shall offer comprehensive coverage to every eligible person who is not eligible for Medicare and public programs as defined in this Subpart. Comprehensive coverage offered by the plan shall pay an eligible person's covered expenses, subject to limits on the deductible and coinsurance payments authorized under Paragraph (4) of Subsection E of this Section, up to a maximum lifetime benefit as established by the board of not less than five hundred thousand dollars per covered person, payable up to a maximum of two hundred fifty thousand dollars per covered person per twelve consecutive months of coverage. For federally defined eligible persons, the board shall establish benefits and maximum benefit amounts in accordance with applicable federal law and regulations.
B. Covered expenses shall be the usual, customary, and reasonable charge, as established by the board, in the locality for the following services and articles when prescribed by a physician and determined by the plan to be medically necessary for the following areas of services:
(1) Hospital services.
(2) Professional services for the diagnosis or treatment of injuries, illnesses, or conditions which are rendered by a health care provider or by other licensed professionals at the direction of a health care provider.
(3) Services of a licensed skilled nursing facility for up to a maximum of one hundred twenty days per twelve consecutive months of coverage, unless extended for additional days under any cost containment program implemented by the board pursuant to Subsection H of this Section.
(4) Services of a home health agency up to a maximum of two hundred seventy services per twelve consecutive months of coverage, unless increased under any cost containment program implemented by the board pursuant to Subsection H of this Section.
(5) Use of radium or other radioactive materials.
(6) Oxygen.
(7) Anesthetics.
(8) Prostheses other than dental.
(9) Rental of durable medical equipment, other than eyeglasses and hearing aids, for which there is no personal use in the absence of the conditions for which it is prescribed.
(10) Diagnostic X-rays and laboratory tests.
(11) Oral surgery for excision of partially or completely unerupted, impacted teeth or the gums and tissues of the mouth when not performed in connection with the extraction or repair of other teeth.
(12) Services of a physical therapist.
(13) Transportation provided by a licensed ambulance service to the nearest facility qualified to treat the condition.
(14) Services for diagnosis and treatment of mental and nervous disorders provided that a covered person may be required to pay up to a fifty percent coinsurance payment, and the plan's payment may not exceed twenty-five thousand dollars. Notwithstanding the previous provision, the department may conduct a periodic actuarial cost analysis to determine whether the plan's maximum payment for outpatient services for diagnosis and treatment of mental and nervous disorders should be adjusted.
C. The board shall establish reasonable reimbursement amounts for any services covered under the benefits plans which are not included in Subsection B of this Section.
D. Covered expenses shall not include the following, except as mandated by applicable federal law for federally defined eligible individuals:
(1) Any charge for treatment for cosmetic purposes other than surgery for the repair or treatment of an injury or a congenital bodily defect to restore normal bodily functions.
(2) Care which is primarily for custodial purposes.
(3) Any charge for confinement in a private room to the extent surcharge is in excess of the institution's charge for its most common semiprivate room, unless a private room is prescribed as medically necessary by a physician.
(4) That part of any charge for services rendered or articles prescribed by a physician, dentist, or other health care provider which exceeds the reasonable reimbursement amounts established in Subsections B and C of this Section or for any charge not medically necessary.
(5) Any charge for services or articles the provision of which is not within the scope of authorized practice of the institution or individual providing the services or articles.
(6) Any expense incurred prior to the effective date of coverage by the plan for the person on whose behalf the expense is incurred.
(7) Dental care except as provided in Subsection B of this Section.
(8) Eyeglasses and hearing aids.
(9) Illness or injury due to acts of war.
(10) Services of blood donors and any fee for failure to replace the first three pints of blood provided to an eligible person each policy year.
(11) Personal supplies or personal services provided by a hospital or nursing home, or any other nonmedical or nonprescribed supply or service.
E.(1) Premiums charged for coverages issued by the plan may not be unreasonable in relation to the benefits provided, the risk experience, and the reasonable expenses of providing the coverage.
(2) Separate schedules of premium rates based on age, sex, and geographical location may apply for individual risks. Separate schedules of premium rates for federally defined eligible individuals may be based on age, sex, and geographical location, in accordance with applicable federal laws and regulations.
(3)(a) The plan, with the assistance of the commissioner, shall determine the standard risk rate by calculating the average individual standard rate charged by the five largest insurers offering coverages in the state comparable to the plan coverage. In the event five insurers do not offer comparable coverage, the standard risk rate shall be established using reasonable actuarial techniques and shall reflect anticipated experience and expenses for such coverage.
(b) Standard risk rates for federally defined eligible individuals shall comply with all applicable federal laws and regulations. Initial rates for plan coverage for federally defined eligible individuals shall not be less than one hundred twenty-five percent of rates established as applicable for individual standard risks. In no event shall plan rates exceed two hundred percent of rates applicable to the individual standard risks.
(c) Initial rates for plan coverage provided to nonfederally defined eligible individuals shall not be less than one hundred fifty percent of rates established as applicable for individual standard risks, or the minimum monthly rates as provided for herein, whichever is greater. Subsequent rates provided to nonfederally defined eligible individuals shall be established to provide fully for the expected costs of claims, including recovery of prior losses, expenses of operation, investment income of claim reserves, and any other cost factors subject to the limitations described herein. In no event shall plan rates exceed two hundred percent of rates applicable to individual standard risks. In no event shall rates be lower than one hundred ten percent of rates applicable to individual standard risks.
(4) The plan coverage defined in this Section shall provide benefits, deductibles, coinsurance, and copayments to be established by the board. In addition, the board may establish optional benefits, deductibles, coinsurance, and copayments.
F. Plan coverage provided to non-federally defined eligible individuals shall exclude charges or expenses incurred for or caused by preexisting conditions as allowed under R.S. 22:1073(A)(1)(b), except that no preexisting condition exclusion shall be applied to a federally defined eligible individual.
G.(1) Notwithstanding any other law to the contrary, the coverage provided by the plan shall be considered excess coverage, and benefits otherwise payable under plan coverage shall be reduced by all hospital and medical expense benefits paid or payable under any workers' compensation coverage, automobile medical payment, or liability insurance whether provided on the basis of fault or nonfault, and by any hospital or medical benefits paid or payable by any insurer or insurance arrangement or any hospital or medical benefits paid or payable under or provided pursuant to any state or federal law or program.
(2) The plan shall have a cause of action against an eligible person for the recovery of the amount of benefits paid by it which are not covered expenses. Benefits due from the plan may be reduced or refused as a set-off against any amount recoverable under this Paragraph.
H. The benefits plan offered pursuant to this Section shall include such managed care provisions as the board deems necessary and proper for:
(1) Compliance with applicable federal laws and regulations regarding choices of benefit coverage for federally defined eligible individuals.
(2) Containment of costs, including precertification and concurrent or continued stay review of hospital admissions, mandatory outpatient surgical procedures, preadmission testing, or any other provisions determined by the board to be cost effective and consistent with the purposes of this Subpart.
I. Except as otherwise provided in this Subpart and in R.S. 22:976, this Section shall establish the exclusive means for determining the benefits required to be offered by the plan, notwithstanding any mandatory benefits or required policy provisions in this Title to the contrary.
NOTE: Former R.S. 22:1213 redesignated as R.S. 22:1963 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.