La. Admin. Code tit. 37 § XIII-11109

Current through Register Vol. 50, No. 9, September 20, 2024

Section XIII-11109 - Enrollment Notification Procedures for a Qualifying Newborn Child

A. Upon notification of the birth of a newborn child who is potentially eligible under Title XIX of the Social Security Act, the health insurance issuer shall be required to:

1. verify that dependant coverage is available for the newborn child or make a determination that no coverage is available for the newborn child;

2. make a determination of the benefit limits with regard to the newborn child;

3. make a determination of any additional premium, if applicable, that may be due in order to provide dependent coverage for the newborn child; and

4. designate a point of contact (which may be a specific position), with telephone number and physical address, to represent the health insurance issuer to facilitate all matters relative to the newborn child.

B. Upon notification of the birth of a newborn child who is potentially eligible under Title XIX of the Social Security Act, the health insurance issuer shall be required to notify the following persons:

1. with regard to an individual policy, the policyholder;

2. with regard to a group policy, both the employer and the employee;

3. with regard to either an individual policy or a group policy, the health care facility that rendered any medical service to the newborn child from the moment of birth until such time as the infant is discharged from said health care facility to his or her home.

C. The notification that the health insurance issuer is required to send to the persons referred to in Subsection B above shall include the following information:

1. verification as to whether the health plan provides coverage under which the newborn child could be enrolled as a dependent or, if such coverage is not available under the health care plan, an explanation of why such coverage is not available;

2. the additional amount of premium due, if any, in order to provide dependent coverage for the newborn child;

3. designate a point of contact (which may be a specific position), with telephone number and physical address, to represent the health insurance issuer to facilitate all matters relative to the newborn child; and

4. statement to the policyholder under an individual policy or the employee and employer under a group plan that additional information is needed by the health insurance issuer. A health insurance issuer may request that the signature of the policyholder of an individual policy or employee and employer under a group plan be on the enrollment form. However, the failure of the policyholder or employee or employer, as applicable, to place a signature on the enrollment form shall not be a requirement for the enrollment of the newborn child, as the newborn child is enrolled as a matter of law.

D. The health insurance issuer shall be required to provide 90 days written notice to the Secretary of the Department of Health and Hospitals prior to the cancellation of health coverage for a potential qualifying newborn child. This notice shall provide the following documents and/or information:

1. the group identification/policy number or the individual identification/policy number, as applicable, including, but not limited to, the major medical identification number and the prescription drug identification number;

2. summary of benefits, including, but not limited to, an itemization of all covered benefits and applicable co-payments and deductibles;

3. amount of additional premium due in order to provide dependent coverage for the newborn child, including, but not limited to, the total premium (month or portion of a month) due to effectuate coverage for the newborn child from the date of birth;

4. the name(s) of the member subscriber of the newborn child, including, but not limited to, the name(s) of any and all other dependent(s) and the effective date of coverage for each person(s) named as a dependent;

5. designate a point of contact (which may be a specific position), with telephone number and physical address, to represent the health insurance issuer to facilitate all matters relative to the newborn child.

E. Additionally, no later than three days after the mailing of the written notice to the Secretary of the Department of Health and Hospitals referred to in Subsection D above, the health insurance issuer shall provide the same documents and/or information to any and all health care facilities and any and all health care providers who, prior to or on the date of the notice of cancellation, have either:

1. submitted a claim to the health insurance issuer for health care services rendered to the newborn child; or

2. provided notice to the health insurance issuer that it is rendering or has rendered health care services to the newborn child.

F. The Secretary of the Department of Health and Hospitals shall have 90 days, commencing the day after the secretary receives the written notice, via certified mail, return receipt requested, from the health insurance issuer as provided in Subsection D above, to pay the applicable additional premium attributable to the newborn child to retain the newborn child as a covered dependent under the policy of health insurance.

G. If that portion of the applicable additional premium attributable to the newborn child being retained as a covered dependent under the policy of health insurance remains unpaid after the expiration of the 90 day written notice time period referred to in Subsection E above to the Secretary of Department of Health and Hospitals, the health insurance issuer may thereafter cancel the dependent coverage for the newborn child effective as of the date of birth of the newborn child.

La. Admin. Code tit. 37, § XIII-11109

Promulgated by the Department of Insurance, Office of the Commissioner, LR 31:2260 (September 2005).

AUTHORITY NOTE: Promulgated in accordance with R.S. 22:3 to implement and enforce the provisions of R.S. 22:250.2.E.(2)(b) and (c), and 22:250.4.F, and 22:250.11.E, and 22:250.15.A of Part VI-C of Chapter 1 of Title 22 of the Louisiana Revised Statutes of 1950, as amended.