§976.1. Fairness in enrollee cost sharing
A. As used in this Section the following definitions shall apply:
(1)"Cost-sharing requirement" means any copayment, coinsurance, deductible, or
annual limitation on cost-sharing including but not limited to a limitation subject to 42
U.S.C. 18022(c) and 300gg-6(b), required by or on behalf of an enrollee in order to receive
a specific healthcare service, including a prescription drug, covered by a health benefit plan. (2)"Enrollee" means an individual who is enrolled or insured by a health insurance
issuer for healthcare services.
(3)"Health benefit plan" means healthcare services provided directly through
insurance, reimbursement, or other means, and including items and services paid for as
healthcare services under any hospital or medical ser
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§976.1. Fairness in enrollee cost sharing
A. As used in this Section the following definitions shall apply:
(1) "Cost-sharing requirement" means any copayment, coinsurance, deductible, or
annual limitation on cost-sharing including but not limited to a limitation subject to 42
U.S.C. 18022(c) and 300gg-6(b), required by or on behalf of an enrollee in order to receive
a specific healthcare service, including a prescription drug, covered by a health benefit plan.
(2) "Enrollee" means an individual who is enrolled or insured by a health insurance
issuer for healthcare services.
(3) "Health benefit plan" means healthcare services provided directly through
insurance, reimbursement, or other means, and including items and services paid for as
healthcare services under any hospital or medical service policy or certificate, hospital or
medical service plan contract, preferred provider organization contract, or health
maintenance organization contract offered by a health insurance issuer.
(4) "Health insurance issuer" means any entity that offers health insurance coverage
through a health benefit plan, policy, or certificate of insurance subject to state law that
regulates the business of insurance. "Health insurance issuer" includes a health maintenance
organization as defined and licensed pursuant to Subpart I of Part I of Chapter 2 of this Title
and the office of group benefits as created pursuant to Chapter 12 of Title 42 of the Louisiana
Revised Statutes of 1950.
(5) "Healthcare services" means items or services furnished to any individual for the
purpose of preventing, alleviating, curing, or healing human illness, injury, or a mental or
physical disability.
(6) "Person" means a natural person, corporation, mutual company, unincorporated
association, partnership, joint venture, limited liability company, trust, estate, foundation,
not-for-profit corporation, unincorporated organization, government or governmental
subdivision, or agency.
B. When calculating an enrollee's contribution to any applicable cost-sharing
requirement, a health insurance issuer shall include any cost-sharing amounts paid by the
enrollee or on behalf of the enrollee by another person. If application of this requirement
results in health savings account ineligibility under 26 U.S.C. 223, this requirement shall
apply for health savings account-qualified high deductible health plans with respect to the
deductible of the plan after the enrollee has satisfied the minimum deductible under 26
U.S.C. 223, except with respect to items or services that are preventive care pursuant to 26
U.S.C. 223(c)(2)(C), in which case the requirements of this Subsection shall apply regardless
of whether the minimum deductible under 26 U.S.C. 223 has been satisfied.
C. In implementing the requirements of this Section, the state shall regulate a health
insurance issuer only to the extent permissible under applicable law.
D. The commissioner of insurance may promulgate rules and regulations in
accordance with the Administrative Procedure Act as are necessary to implement this
Section.