RS 22:1068

§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. Acts 1997, No. 1138, §1, eff. July 14, 1997; Acts 1999, No. 127, §1, eff. June 9, 1999; Redesignated from R.S. 22:250.7 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009; Acts 2010, No. 484, §1, eff. Sept. 23, 2010; Acts 2010, No. 595, §1; Acts 2011, No. 350, §1, eff. Jan. 1, 2012; Acts 2012, No. 316, §1, eff. May 25, 2012; Acts 2020, No. 36, §1; Acts 2021, No. 217, §1. NOTE: Former R.S. 22:1068 redesignated as R.S. 22:832 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.