SLS 15RS-511 RE-REENGROSSED
2015 Regular Session
SENATE BILL NO. 173
BY SENATOR HEITMEIER
Prefiled pursuant to Article III, Section 2(A)(4)(b)(i) of the Constitution of Louisiana.
HEALTH CARE. Provides for treatment of morbid obesity. (1/1/17)
1 AN ACT
2 To enact R.S. 22:1055, relative to morbid obesity; to provide for health insurance coverage
3 for the treatment of morbid obesity; to provide for definitions; to provide for an
4 effective date; and to provide for related matters.
5 Be it enacted by the Legislature of Louisiana:
6 Section 1. R.S. 22:1055 is hereby enacted to read as follows:
7 ยง1055. Health insurance coverage for the treatment of morbid obesity;
8 definitions
9 A. As used in this Section, the following definitions shall apply:
10 (1) "Body mass index" means a practical marker used to assess the
11 degree of obesity and is calculated by dividing the weight in kilograms by the
12 height in meters squared.
13 (2) "Morbid obesity" means the condition that exists when a person has
14 a body mass index greater than forty kilograms per meter squared and also has
15 the two comorbidity factors of diabetes and hypertension.
16 B.(1) Any group insurance plan providing comprehensive major medical
17 benefits which is issued or renewed in this state on or after January 1, 2017, or,
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Coding: Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions. SB NO. 173
SLS 15RS-511 RE-REENGROSSED
1 notwithstanding the provisions of R.S. 22:1016, any prepaid entity that
2 participates in the Louisiana Medicaid Program shall provide coverage for the
3 medically necessary expenses of the diagnosis and treatment of morbid obesity
4 as defined in this Section, including but not limited to bariatric surgery,
5 physician office visits, health and behavior assessments, nutrition education,
6 and patient self-management education training. This provision shall not apply
7 to the Office of Group Benefits or to small group insurance plans or to
8 grandfathered large group plans as defined by the Patient Protection and
9 Affordable Care Act, Public Law 111-148, as amended by the Health Care and
10 Education Reconciliation Act, Public Law 111-152.
11 (2) The coverage required pursuant to this Section for bariatric surgery
12 shall be limited to facilities of surgical services that are accredited by the
13 Metabolic and Bariatric Surgery Accreditation and Quality Improvement
14 Program of the American College of Surgeons and the American Society for
15 Metabolic Bariatric Surgery as a comprehensive bariatric facility. A health
16 insurance issuer providing coverage pursuant to this Section may limit such
17 coverage to services provided by a specific limited network of providers based
18 on quality and efficiency factors.
19 (3) Notwithstanding any provision of law to the contrary, the fee
20 schedule used for the payment of services associated with the treatment of
21 morbid obesity shall be the same as the fee schedule used by the Louisiana
22 Medicaid Bayou Health program.
23 C. The Heads Up Program, which operates as a partnership between the
24 Office of Group Benefits and the Pennington Biomedical Research Center, shall
25 continue to serve one hundred surgical participants annually through June 30,
26 2017, or beyond, at the discretion of the Office of Group Benefits.
27 D. A health insurance issuer shall only be required to cover the services
28 described in this Section to persons between the ages of seventeen and sixty-five
29 years of age.
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SLS 15RS-511 RE-REENGROSSED
1 E. For coverage of any surgery under this Section, a health insurance
2 issuer may establish the following limitations on such coverage:
3 (1) Require that the insured and his provider provide documented
4 evidence that he has exhausted all reasonable, nonsurgical options prior to
5 seeking surgery as provided by the Centers for Medicare and Medicaid Services
6 National Coverage Determination for Bariatric Surgery. Such options shall
7 include but not be limited to diet, exercise, and approved medications.
8 (2) Establish guidelines for the insured and his provider to follow that
9 ensure that candidates for surgery receive comprehensive medical and
10 behavioral clearance from the provider prior to being approved for surgery.
11 (3) Limit coverage for surgery to not more than one surgery per lifetime
12 for any insured, unless surgery is required due to complications due to a prior
13 surgery covered in accordance with this Section.
14 (4) Limit the benefit payable for any surgical procedure to not more than
15 fifteen thousand dollars per lifetime. Any additional amounts payable for such
16 surgery shall be the responsibility of the insured.
17 F. A health insurance issuer providing coverage under this Section may
18 exclude coverage for the following items:
19 (1) Any membership or access fee charged by a provider.
20 (2) Meals or meal supplements.
21 Section 2. This Act shall become effective on January 1, 2017.
The original instrument was prepared by Christopher D. Adams. The
following digest, which does not constitute a part of the legislative
instrument, was prepared by Nancy Vicknair.
DIGEST
SB 173 Re-Reengrossed 2015 Regular Session Heitmeier
Proposed law provides for health insurance coverage for the treatment of morbid obesity
which is defined as the condition that exists when a person has a body mass index greater
than 40 kilograms per meter squared and also has the two comorbidity factors of diabetes
and hypertension.
Proposed law defines "body mass index" to mean a practical marker used to assess the
degree of obesity and is calculated by dividing the weight in kilograms by the height in
meters squared.
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Coding: Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions. SB NO. 173
SLS 15RS-511 RE-REENGROSSED
Proposed law requires any group insurance plan providing comprehensive major medical
benefits which is issued or renewed in this state on or after January 1, 2017, or,
notwithstanding the provisions of R.S. 22:1016, any prepaid entity that participates in the
Louisiana Medicaid Program to provide coverage for the medically necessary expenses of
the diagnosis and treatment of morbid obesity as defined in proposed law, including but not
limited to bariatric surgery, physician office visits, health and behavior assessments,
nutrition education, and patient self-management education training. This provision shall
not apply to the Office of Group Benefits nor to small group insurance plans or to
grandfathered large group plans as defined by federal law.
Proposed law provides the coverage required pursuant to proposed law for bariatric surgery
shall be limited to facilities of surgical services that are accredited by the Metabolic and
Bariatric Surgery Accreditation and Quality Improvement Program of the American College
of Surgeons and the American Society for Metabolic Bariatric Surgery as a comprehensive
bariatric facility. Proposed law authorizes health insurance issuers providing coverage
pursuant to proposed law to limit such coverage to services provided by a specific limited
network of providers based on quality and efficiency factors.
Proposed law requires the fee schedule used for payment of services associated with the
treatment of morbid obesity to be the same as the fee schedule used by the Louisiana
Medicaid Bayou Health program.
Proposed law requires the Heads Up Program operated by the Office of Group Benefits and
the Pennington Biomedical Research Center to continue to serve 100 surgical participants
annually through June 30, 2017, or beyond, at the direction of the Office of Group Benefits.
Proposed law provides that a health insurance insurer is only required to cover the services
provided for in proposed law to persons between the ages of 17 and 65 years of age.
Proposed law authorizes a health insurance issuer to establish the following limitations
regarding any surgery provided for in proposed law:
(1)Require that the insured and his provider provide documented evidence that he has
exhausted all reasonable, nonsurgical options prior to seeking surgery as provided
by the Centers for Medicare and Medicaid Services National Coverage
Determination for Bariatric Surgery. Such options shall include but not be limited
to diet, exercise, and approved medications.
(2)Establish guidelines for the insured and his provider to follow that ensure that
candidates for surgery receive comprehensive medical and behavioral clearance from
the provider prior to being approved for surgery.
(3)Limit coverage for surgery to not more than one surgery per lifetime for any insured,
unless surgery is required due to complications due to a prior surgery covered in
accordance with proposed law.
(4)Limit the benefit payable for any surgical procedure to not more than $15,000 per
lifetime. Any additional amounts payable for such surgery shall be the responsibility
of the insured.
Proposed law authorizes a health insurance issuer providing coverage under proposed law
to exclude coverage for the following items:
(1) Any membership or access fee charged by a provider.
(2)Meals or meal supplements.
Effective January 1, 2017.
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Coding: Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions. SB NO. 173
SLS 15RS-511 RE-REENGROSSED
(Adds R.S. 22:1055)
Summary of Amendments Adopted by Senate
Committee Amendments Proposed by Senate Committee on Insurance to the original
bill
1. Defines morbid obesity.
2. Restricts application only to group health plans.
3. Requires the use of the Louisiana Medicaid Bayou Health fee schedule.
4. Requires the Heads Up program to seek to increase its number of participants
to 300 per year by 2018.
Committee Amendments Proposed by Senate Committee on Finance to the
engrossed bill
1. Clarifies that any group insurance plan offering major medical shall provide
coverage relative to morbid obesity, but such provisions shall not apply to the
Office of Group Benefits (OGB).
2. Provides that the Heads Up Program which operates in partnership with OGB
shall continue to serve 100 surgical participants annually through June 30,
2017, or beyond, at the direction of OGB.
3. Technical amendment.
Senate Floor Amendments to reengrossed bill
1. Makes technical changes.
2. Changes the effective date from October 1, 2015, to January 1, 2017.
3. Removes coverage for therapeutic exercises.
4. Provides that small group insurance plans or grandfathered large group plans
as defined by certain federal laws are exempt from the provisions of
proposed law.
5. Authorizes health insurance issuers providing coverage pursuant to proposed
law to limit such coverage to services provided by a specific limited network
of providers based on certain factors.
6. Provides that health insurance issuers shall only be required to cover the
services provided in proposed law to persons between the ages of 17 and 65.
7. Authorizes health insurance issuers to establish certain limitations on
coverage.
8. Authorizes health insurance issuers to exclude coverage for certain items.
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Coding: Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions.