2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1206. Powers and duties of the plan

RS 22:1206 - Powers and duties of the plan
The plan shall have the general powers and authority granted under the laws of this state to insurance companies licensed to provide health and accident insurance and, in addition thereto, the specific authority to:
(1) Contract with an outside independent actuarial firm to assess the solvency of the plan and for consultation as to the sufficiency and means of the funding of the plan, and the enrollment in and the eligibility, benefits, and rate structure of the benefits plan to ensure the solvency of the plan.
(2) Close enrollment in benefit plans of non-federally defined eligible individuals at any time upon a determination by the outside independent actuarial firm that funds of the plan are insufficient to support the enrollment of additional non-federally defined eligible individuals.
(3) Enter into contracts as are necessary or proper to carry out the provisions and purposes of this Subpart, including the authority to enter into contracts, with the approval of the commissioner, with similar plans or pools of other states for the joint performance of common administrative functions, or with persons or other organizations for the performance of administrative functions.
(4) Enter into contracts for the establishment and maintenance of health care cost containment programs as in the discretion of the board are necessary or proper to establish the most cost-efficient levels of coverage as provided herein.
(5) Sue or be sued, including taking any legal actions necessary or proper for recovery of any monies due the plan under this Subpart.
(6) Take such legal action as necessary to avoid the payment of improper claims against the plan or the coverage provided by or through the plan.
(7) Establish appropriate rates, rate schedules, rate adjustments, expense allowances, agent's referral fees, and claim reserve formulas, and perform or contract for the performance of any other actuarial function appropriate to the operation of the plan, subject to the following limitations:
(a) Rates for federally defined individuals and nonfederally defined individuals. (i) For federally defined individuals, subject to approval by the Department of Insurance, the plan shall determine a standard risk rate for each coverage option offered by considering the premium rates charged by other insurers offering similar health insurance coverage to individuals and family groups, if applicable. The standard risk rate shall be established using reasonable actuarial techniques and shall reflect anticipated experience and expenses for such coverage. Subject to the limits provided in this Paragraph, initial rates for each plan year 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, provided such rates shall not exceed two hundred percent of rates applicable to individual standard risks. Upon the receipt of governmental appropriations or alternative funding sources, other than assessments under R.S. 22:1210, such as authorized service charges, governmental transfer payments, donations, or grants, the board shall be authorized to reduce rates for the plan year based on established actuarial and underwriting practices. In no event shall rates for plan coverage be less than the greater of one hundred twenty-five percent of rates established as applicable for individual standard risks or rates established for other individuals provided coverage by or through the plan unless such rates would exceed the maximum amount allowed under this Paragraph. In no instance shall the rates discriminate between covered individuals on the basis of health-related factors.
(ii) Rates for nonfederally defined individuals. For nonfederally defined individuals, subject to approval by the Department of Insurance, the plan shall determine a standard risk rate for each coverage option offered by considering the premium rates charged by other insurers offering similar health insurance coverage to individuals and family groups, if applicable. The standard risk rate shall be established using reasonable actuarial techniques and shall reflect anticipated experience and expenses for such coverage. Subject to the limits provided in this Paragraph, initial rates for each plan year 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 of prior losses, expenses of operation, investment income of claim reserves, and any other cost factors subject to the limitations described herein, provided such rates shall not exceed two hundred percent of rates applicable to individual standard risks. Upon the receipt of governmental appropriations or alternative funding sources, such as authorized service charges, governmental transfer payments, donations, or grants, the board shall be authorized to reduce rates for the plan year based on established actuarial and underwriting practices. In no event shall rates for plan coverage be less than one hundred ten percent of rates established as applicable for individual standard risks or rates established for other individuals provided coverage by or through the plan, provided such rates shall not exceed the maximum amount of two hundred percent of rates applicable to individual standard rates. In no instance shall the rates discriminate between covered individuals on the basis of health-related factors.
(iii) Notwithstanding any other provision of this Subpart to the contrary, for persons eligible under a federal waiver pursuant to R.S. 22:1207(B)(2), the board may authorize a premium subsidy if such a premium subsidy is authorized by the federal waiver. If the board authorizes a premium subsidy, the total amount of the subsidy may not be more than sixty-six percent of the premium otherwise specified by this Subpart. The board may authorize the Louisiana Health Plan to provide for the nonfederal share of such premium subsidy. Nothing herein shall permit rates to be calculated other than as described in this Subpart, or otherwise restrict the board from participating in other components of the federal waiver.
(b) Rates for other individuals. (i) Rates shall not be unreasonable in relation to the coverage provided, the risk experience, and expenses of providing the coverage. Rates and rate schedules may be adjusted for appropriate risk factors such as age and area variation in claim cost and shall take into consideration appropriate risk factors in accordance with established actuarial and underwriting practices. In no instance shall the rates discriminate between covered individuals on the basis of health-related factors.
(ii) Notwithstanding any other provision of this Subpart to the contrary, for persons eligible under a federal waiver pursuant to R.S. 22:1207(D)(2), the board may authorize a premium subsidy if such a premium subsidy is authorized by the federal waiver. If the board authorizes a premium subsidy, the total amount of the subsidy may not be more than sixty-six percent of the premium otherwise specified by this Subpart. The board may authorize the Louisiana Health Plan to provide for the non-federal share of such premium subsidy. Nothing herein shall permit rates to be calculated other than as described in this Subpart, or otherwise restrict the board from participating in other components of the federal waiver.
(c) Policy fees or other compensation, or consideration paid to agents. No agent's fees or other compensation, or consideration shall be payable for coverage offered through the plan unless:
(i) The agent is duly registered and certified by the plan under a plan approved by the commissioner of insurance.
(ii) The agent certifies in writing that to the best of his knowledge the individual is a qualifying individual as defined by R.S. 22:1207 or 1073(B).
(iii) The agent has entered into a participation agreement with the plan which provides for recoupment of amounts paid for certifications found to be erroneous.
(d) Reimbursement of expenses. The board shall be authorized to establish policy fees or other compensation, or consideration for reimbursement of the reasonable expenses of participating agents. The plan shall be authorized to recoup any amounts paid for an agent certification found to be erroneous or improper.
(8) Issue individual and family group policies of insurance in accordance with the requirements of this Subpart.
(9) Appoint appropriate legal, actuarial, and other committees as necessary to provide technical assistance in the operation of the plan, policy and other contract design, and any other function within the authority of the plan.
(10) Repealed by Acts 2004, No. 493, §2, eff. June 25, 2004.
Acts 1990, No. 131, §1, eff. Sept. 1, 1990; Acts 1997, No. 1154, §1, eff. Jan. 1, 1998; Acts 1999, No. 163, §1; Acts 2003, No. 528, §1, eff. June 24, 2003; Acts 2004, No. 493, §2, eff. June 25, 2004; Acts 2005, No. 154, §1, eff. June 28, 2005; Acts 2008, No. 21, §1; Redesignated from R.S. 22:236 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.
NOTE: Former R.S. 22:1206 redesignated as R.S. 22:1626 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.