La. Admin. Code tit. 37 § XIII-303
A. As used in this regulation, these words and terms have the following meanings, unless the context clearly indicates otherwise.
Allowable Expense- a health care service or expense including deductibles, coinsurance, or copayments that are covered in full or in part by any of the plans covering the person, except as set forth below or where a statute requires a different definition. This means that an expense or service or a portion of an expense or service that is not covered by any of the plans is not an allowable expense.
a. The following are examples of expenses or services that are and are not an allowable expense.
i. If a covered person is confined in a private hospital room, the difference between the cost of a semi-private room in the hospital and the private room, (unless the patient's stay in the private hospital room is medically necessary in terms of generally accepted medical practice, or one of the plans routinely provides coverage for private hospital rooms), is not an allowable expense.
ii. If a person is covered by two or more plans that compute their benefit payments on the basis of usual and customary fees, any amount in excess of the highest of the usual and customary fee for a specified benefit is not an allowable expense.
iii. If a person is covered by two or more plans that provide benefits or services on the basis of negotiated fees, any amount in excess of the highest of the negotiated fees is not an allowable expense.
iv. If a person is covered by one plan that calculates its benefits or services on the basis of usual and customary fees and another plan that provides its benefits or services on the basis of negotiated fees, the primary plan's payment arrangement shall be the allowable expense for all plans.
b. The definition of allowable expense may exclude certain types of coverage or benefits such as dental care, vision care, prescription drug, or hearing aids. A plan that limits the application of COB to certain coverages or benefits may limit the definition of allowable expenses in its contract to services or expenses that are similar to the services or expenses that it provides. When COB is restricted to specific coverages or benefits in a contract, the definition of allowable expense shall include similar services or expenses to which COB applies.
c. When a plan provides benefits in the form of services, the reasonable cash value of each service will be considered an allowable expense and a benefit paid.
d. The amount of the reduction may be excluded from allowable expense when a covered person's benefits are reduced under a primary plan:
i. because the covered person does not comply with the plan provisions concerning second surgical opinions or pre-certification of admissions or services; or
ii. because the covered person has a lower benefit because he or she did not use a preferred provider.
e. If the primary plan is a closed panel plan and the secondary plan is not a closed panel plan, the secondary plan shall pay or provide benefits as if it were primary when a covered person uses a nonpanel provider, except for emergency services or authorized referrals that are paid or provided by the primary plan.
f. When a plan provides benefits in the form of services, the reasonable cash value of each service will be considered an allowable expense and a benefit paid.
g. The amount of the reduction may be excluded from allowable expense when a covered persons benefits are reduced under a primary plan:
i. because the covered person does not comply with the plan provisions concerning second surgical opinions or precertification of admissions or services; or
ii. because the covered person has a lower benefit because the covered person did not use a preferred provider. Birthday-refers only to month and day in a calendar year and does not include the year in which the individual is born. Claim-a request that benefits of a plan be provided or paid. The benefits claimed may be in the form of:
a. services (including supplies);
b. payment for all or a portion of the expenses incurred;
c. a combination of Subparagraphs a and b of this Paragraph; or
d. an indemnification.
Claim Determination Period or Plan Year-a period of not less than 12 consecutive months over which allowable expenses shall be compared with total benefits payable in the absence of COB to determine whether overinsurance exists and how much each plan will pay or provide.
a. The claim determination period is usually a calendar year, but a plan may use some other period of time that fits the coverage of the group or individual contract. A person is covered by a plan during a portion of a claim determination period if that person's coverage starts or ends during the claim determination period.
b. As each claim is submitted, each plan determines its liability and pays or provides benefits based upon allowable expenses incurred to that point in the claim determination period. That determination is subject to adjustment as later allowable expenses are incurred in the same claim determination period.
Closed Panel Plan- a plan that provides health benefits to covered persons primarily in the form of services through a panel of providers that have contracted with or are employed by the plan, and that excludes benefits for services provided by other providers, except in cases of emergency or referral by a panel member.
Consolidated Omnibus Budget Reconciliation Act of 1985 or COBRA-coverage provided under a right of continuation pursuant to federal law.
Coordination of Benefits or COB-a provision establishing an order in which plans pay their claims, and permitting secondary plans to reduce their benefits so that the combined benefits of all plans do not exceed total allowable expenses. Custodial Parent-
a. the parent awarded custody of a child by a court decree; or
b. in the absence of a court decree, the parent with whom the child resides more than one half of the calendar year without regard to any temporary visitation.
Group-Type Contract-a contract that is not available to the general public and is obtained and maintained only because of membership in or a connection with a particular organization or group, including blanket coverage. Group type contract does not include an individually underwritten and issued guaranteed renewable policy even if the policy is purchased through payroll deduction at a premium savings to the insured since the insured would have the right to maintain or renew the policy independently of continued employment with the employer.
High-Deductible Health Plan-the meaning given the term under section 223 of the Internal Revenue Code of 1986, as amended by the Medicare Prescription Drug, Improvement and Modernization Act of 2003.
Hospital Indemnity Benefits-benefits not related to expenses incurred. Hospital indemnity benefits does not include reimbursement-type benefits even if they are designed or administered to give the insured the right to elect indemnity-type benefits at the time of claim.
Plan-a form of coverage with which coordination is allowed. Separate parts of a plan for members of a group that are provided through alternative contracts that are intended to be part of a coordinated package of benefits are considered one plan and there is no COB among the separate parts of the plan. If a plan coordinates benefits, its contract shall state the types of coverage that will be considered in applying the COB provision of that contract. Whether the contract uses the term "plan" or some other term such as "program," the contractual definition may be no broader than the definition of "plan" in this subsection. The definition of "plan" in the model COB provision in Appendix A of §321 of this Chapter is an example.
a. Plan includes:
i. group and nongroup insurance contracts and subscriber contracts;
ii. uninsured arrangements of group or group-type coverage;
iii. group and nongroup coverage through closed panel plans;
iv group-type contracts;
v. the medical care components of long-term care contracts, such as skilled nursing care;
vi. the medical benefits coverage in automobile "no fault" and traditional automobile "fault" type contracts;
vii. Medicare or other governmental benefits, as permitted by law, except as provided in Subparagraph b of this Paragraph. That part of the definition of plan may be limited to the hospital, medical and surgical benefits of the governmental program; and
viii. group and nongroup insurance contracts and subscriber contracts that pay or reimburse for the cost of dental care.
b. Plan does not include:
i. hospital indemnity coverage benefits or other fixed indemnity coverage;
ii. accident only coverage;
iii. specified disease or specified accident coverage;
iv. limited benefit health coverage as defined in R.S. 22:47(2)(c);
v. school accident-type coverages that cover students for accidents only, including athletic injuries, either on a 24-hour basis or on a "to and from school" basis;
vi. benefits provided in long-term care insurance policies for non-medical services, for example, personal care, adult day care, homemaker services, assistance with activities of daily living, respite care and custodial care or for contracts that pay a fixed daily benefit without regard to expenses incurred or the receipt of services;
vii. Medicare supplement policies;
viii. a state plan under Medicaid; or
ix. a governmental plan, which, by law, provides benefits that are in excess of those of any private insurance plan or other non-governmental plan.
Policyholder or Subscriber-the primary insured named in a nongroup insurance policy.
Primary Plan-a plan whose benefits for a persons health care coverage must be determined without taking the existence of any other plan into consideration. A plan is a primary plan if:
a. the plan either has no order of benefit determination rules, or its rules differ from those permitted by this regulation; or
b. all plans that cover the person use the order of benefit determination rules required by this regulation, and under those rules the plan determines its benefits first. Provider-a health care professional or health care facility. Secondary Plan-a plan that is not a primary plan.
La. Admin. Code tit. 37, § XIII-303