Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 101 - Regulation 78-Policy Form Filing Requirements › Section XIII-10107 - Filing and Review of Health Insurance Policy Forms and Related Matters

Current through Register Vol. 50, No. 6, June 20, 2024
A. Definitions. As
				used in this Section, the following terms shall have the meaning or definition
				as indicated herein.
Affirmative Approval
-department approval, as
				  a result of the department taking action, following compliance review of a
				  complete filing, or a filing pursuant to Subsection D hereof
Association
-an organization legally formed
				  for purposes other than the procurement of insurance and, depending upon the
				  particular insurance products in question, meeting the requirements of
				  R.S.
				  22:1000 A(1)(a)(iv), or
				  R.S.
				  22:1061(5)(b), or
				  R.S.
				  22:1184(4), whichever is
				  applicable.
Benchmark Plan
-a basic insurance policy form
				  establishing the essential health benefits required of every plan sold in
				  Louisiana under the Patient Protection and Affordable Care Act (Pub. L.
				  111-148), as amended by the Health Care and
				  Education and Reconciliation Act of 2010
(Pub.
				  L. 111-152), together referred to as the
				  Affordable Care Act.
Basic Insurance Policy Form
-an insurance
				  contractual agreement delineating the terms, provisions and conditions of a
				  particular insurance product. It includes certificates of coverage and any
				  other evidence of coverage, subscriber agreements, application forms where
				  written application is required and is to be attached to the policy or be a
				  part of the contract, and any life or health and accident rider or endorsement
				  form. It does not include policies, riders, or endorsements designed, at the
				  request of the individual policyholder, contract holder, or certificate holder,
				  to delineate insurance coverage upon a particular subject or which relate to
				  the manner of distribution of benefits or to the reservation of rights and
				  benefits under such policy.
Certification of Compliance
-certification by
				  an insurer, executed by an officer or authorized representative of the insurer
				  on a form prescribed by the department, that upon knowledge and belief a filing
				  is complete and in compliance with all applicable statutes, and rules and
				  regulations promulgated by the department. A certification of compliance must
				  be included with any filing for certified approval.
Certified Approval
-approval on the basis of
				  an expedited review by the department of a complete filing based upon the
				  inclusion of a statement of compliance and a certification of compliance,
				  executed by an officer or authorized representative of the filing insurer on a
				  form prescribed by the department. The department shall by directive determine
				  those specific types of coverages and particular types of contracts for which
				  the certified approval procedure is either required or available at the option
				  of the insurer.
Commissioner
-the commissioner of insurance
				  of the Louisiana Department of Insurance.
Complete Filing
-the filing of a single
				  insurance product, including any required filing fees; a basic insurance policy
				  form, application form and supplemental application form, if any, to be
				  attached to the policy or be a part of the contract; any life or health and
				  accident rider or endorsement forms; all items required under Subsection C
				  hereof, "General Filing Requirements," and any other requirements as may be set
				  forth in the applicable statement of compliance.
Compliance Audit
-a retrospective review
				  conducted by the department of previously approved basic insurance policy forms
				  to determine compliance with applicable law.
Compliance Review
-department review of a
				  filing made pursuant to this Section to determine either that the filing is in
				  compliance with all applicable statutes, rules and regulations, or that the
				  filing should be disapproved for noncompliance.
Deemed Approval
-approval of a complete
				  filing based upon notice, as provided herein, made to the department by the
				  filing insurer, following expiration of the specific time periods as provided
				  herein, where affirmative approval has not been granted and the filing has not
				  been disapproved by the department.
Department
-the Louisiana Department of
				  Insurance.
Endorsement
-a written agreement attached to
				  an insurance product to add or subtract coverage, or otherwise modify the
				  product.
Insurance Product
-a basic insurance policy
				  form delineating the terms, provisions and conditions of a specific type of
				  coverage under a particular type of contract.
Insurer
-every person engaged in the business
				  of making contracts of insurance, as further defined in
				  R.S.
				  22:46(10). As used in this
				  Section,
insurer
shall also include fraternal benefit
				  societies and health maintenance organizations.
Method of Marketing
-marketing either through
				  independent or captive agents; telephone, electronic mail or direct mail
				  solicitation; groups, organizations, associations or trusts; and/or the
				  internet.
Optional Endorsement
or
Rider
-a form used to permit policyholders, certificate
				  holders, or enrollees to obtain supplemental benefits.
Required Filing Fee
-the fee assessed per
				  product or filing pursuant to state insurance law.
Rider
-an endorsement to an insurance product
				  that modifies clauses and provisions of the product, including adding or
				  excluding coverage.
Statement of Compliance
-a form prescribed by
				  the department, detailing the requirements specific to a particular form of
				  coverage and contract type.
Trust
-a fund established by an employer, two
				  or more employers in the same industry, one or more labor unions, an
				  association, multiple associations, or to a multiple employer trust established
				  by an insurer on behalf of participating employers, pursuant to a trust
				  instrument which transfers title to property and/or funds to one or more
				  trustees to be administered as fiduciaries for the benefit of others, pursuant
				  to
				  R.S.
				  22:1000. All participating employers and
				  employees must have the same statutory protections that would apply if such
				  policy was purchased by the employer directly from the insurer.
B. Filing Required
1. Pursuant to
				R.S.
				22:861(A), no basic
				insurance policy form, other than fidelity or surety bond forms, or application
				form where written application is required and is to be attached to the policy
				or be a part of the contract, or printed rider or endorsement form, shall be
				issued, delivered, or used in this state unless and until it has been filed
				with and approved by the commissioner This requirement also applies to any
				group health or accident insurance policy covering residents of Louisiana,
				regardless of where issued or delivered. Every page of each such form including
				rider and endorsement forms filed with the department must be identified by a
				form number in the lower left corner of the page.
2. A filing description must accompany every
				filing, describing the items included in the filing, the insurance product type
				for which the filing is being made, and the method of marketing to be used for
				the product. For nonelectronic paper filings, this description must be
				satisfied by the submission of a completed transmittal document.