HLS 16RS-3381 ORIGINAL
2016 Regular Session
HOUSE BILL NO. 1151 (Substitute for House Bill No. 849 by Representative Robert
Johnson)
BY REPRESENTATIVE ROBERT JOHNSON
INSURANCE/HEALTH: Provides relative to notice and appeal of a change in coverage of
medically necessary prescription drugs and intravenous infusions
1 AN ACT
2To amend and reenact R.S. 22:1060.4(A)(introductory paragraph) and (B) and to enact R.S.
3 22:1060.3(C), relative to coverage of medically necessary prescription drugs and
4 intravenous infusions; to provide for notice by a health insurance issuer making a
5 change in such coverage; to provide relative to an appeal of any such change by the
6 insured; to make certain technical changes; and to provide for related matters.
7Be it enacted by the Legislature of Louisiana:
8 Section 1. R.S. 22:1060.4(A)(introductory paragraph) and (B) are hereby amended
9and reenacted and R.S. 22:1060.3(C) is hereby enacted to read as follows:
10 §1060.3. Continuation of coverage required; other drugs not precluded
11 * * *
12 C.(1) A health insurance issuer proposing to change its coverage of a
13 particular prescription drug or intravenous infusion based on medical necessity shall
14 give notice of the proposed change to an insured currently using that prescription
15 drug who the health insurance issuer determines the change may affect; however,
16 such notice to an insured shall not be required if the health insurance issuer has
17 covered the drug or intravenous infusion for the insured for less than sixty days.
18 Such notice shall be sent at least sixty days prior to the effective date of the proposed
19 change.
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CODING: Words in struck through type are deletions from existing law; words underscored
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HB NO. 1151
1 (2) Any insured receiving such a notice from a health insurance issuer shall
2 have the right to appeal the proposed change during the sixty-day notification period
3 provided for in Paragraph (1) of this Subsection in accordance with the Internal
4 Claims and Appeals Process and External Review Act, R.S. 22:2391 et seq. In filing
5 such an appeal, the insured shall document that his physician or authorized
6 prescriber considers continued use of the drug or intravenous infusion to be
7 medically necessary.
8 §1060.4. Adverse determination
9 A. The refusal of a health insurance issuer to provide benefits to an enrollee
10 for a prescription drug is an adverse determination for the purposes of Subpart F of
11 this Part, R.S. 22:1121 et seq., relative to medical necessity review organizations, the
12 Internal Claims and Appeals Process and External Review Act, R.S. 22:2391 et seq.,
13 if each of the following conditions is met:
14 * * *
15 B. The enrollee may appeal the adverse determination pursuant to Subpart
16 F of this Part, R.S. 22:1121 et seq., relative to medical necessity review
17 organizations. the Internal Claims and Appeals Process and External Review Act,
18 R.S. 22:2391 et seq.
19 Section 2. This Act shall apply only to a health benefit plan delivered, issued for
20delivery, or renewed on or after January 1, 2017. This Act shall not apply to a health benefit
21plan delivered, issued for delivery, or renewed before January 1, 2017.
22 Section 3. This Act shall become effective on January 1, 2017.
DIGEST
The digest printed below was prepared by House Legislative Services. It constitutes no part
of the legislative instrument. The keyword, one-liner, abstract, and digest do not constitute
part of the law or proof or indicia of legislative intent. [R.S. 1:13(B) and 24:177(E)]
HB 1151 Original 2016 Regular Session Robert Johnson
Abstract: Provides relative to notice and appeal of a change in coverage of medically
necessary prescription drugs and intravenous infusions.
Proposed law requires that a health insurance issuer proposing to change its coverage of a
particular prescription drug or intravenous infusion based on medical necessity give notice
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CODING: Words in struck through type are deletions from existing law; words underscored
are additions. HLS 16RS-3381 ORIGINAL
HB NO. 1151
of the proposed change to an insured currently using that prescription drug who the health
insurance issuer determines the change may affect; however, specifies that such notice shall
not be required if the health insurance issuer has covered the drug or intravenous infusion
for the insured for less than 60 days. Requires that any such notice shall be sent at least 60
days prior to the effective date of the proposed change.
Proposed law further provides that any insured receiving such a notice from a health
insurance issuer shall have the right to appeal the proposed change during the 60-day
notification period in accordance with present law, the state's appeals law, the Internal
Claims and Appeals Process and External Review Act. Also requires that, in filing such an
appeal, the insured shall document that his physician or authorized prescriber considers
continued use of the drug or intravenous infusion to be medically necessary.
Proposed law makes certain technical changes, in particular to references and citations to
present law, the state's appeals law, the Internal Claims and Appeals Process and External
Review Act.
Proposed law provides that it shall apply only to a health benefit plan delivered, issued for
delivery, or renewed on or after January 1, 2017, and shall not apply to a health benefit plan
delivered, issued for delivery, or renewed before January 1, 2017.
Effective January 1, 2017.
(Amends R.S. 22:1060.4(A)(intro. para.) and (B); Adds R.S. 22:1060.3(C))
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CODING: Words in struck through type are deletions from existing law; words underscored
are additions.