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2019 Regular Session
SENATE BILL NO. 173
BY SENATOR MILLS
Prefiled pursuant to Article III, Section 2(A)(4)(b)(i) of the Constitution of Louisiana.
HEALTH CARE. Provides for the Healthcare Coverage for Louisiana Families Protection
Act. (gov sig)
1 AN ACT
2 To enact R.S. 22:11.1 and Subpart F of Part III of Chapter 4 of Title 22 of the Louisiana
3 Revised Statutes of 1950, to be comprised of R.S. 22:1121 through 1129, relative to
4 health insurance; to provide relative to enrollment, dependent coverage, rate setting,
5 preexisting conditions, annual and lifetime limits, and essential benefits under certain
6 circumstances; to provide for rulemaking; to provide for effectiveness; and to
7 provide for related matters.
8 Be it enacted by the Legislature of Louisiana:
9 Section 1. R.S. 22:11.1 and Subpart F of Part III of Chapter 4 of Title 22 of the
10 Louisiana Revised Statutes of 1950, comprised of R.S. 22:1121 through 1129, are hereby
11 enacted to read as follows:
12 §11.1. Rules and regulations; essential health benefits package
13 The commissioner shall promulgate rules pursuant to the Administrative
14 Procedure Act to define "essential health benefits", to establish annual
15 limitations on cost sharing and deductibles, and to define required levels of
16 coverage. The commissioner shall adopt initial administrative rules before
17 January 1, 2020. Notwithstanding any provision of R.S. 49:953(B) to the
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1 contrary, the commissioner may adopt initial administrative rules as required
2 by this Section pursuant to the provisions of R.S. 49:953(B) without a finding
3 that an imminent peril to the public health, safety, or welfare exists.
4 * * *
5 SUBPART F. HEALTHCARE COVERAG E FOR LOUISIANA
6 FAMILIES PROTECTION ACT
7 §1121. Short Title
8 This Subpart shall be known and may be cited as the "Healthcare
9 Coverage for Louisiana Families Protection Act".
10 §1122. Effectiveness
11 If a court of competent jurisdiction rules that the Patient Protection and
12 Affordable Care Act, P.L. 111-148, is unconstitutional and the judgment of that
13 court becomes final and definitive, the attorney general shall give written
14 notification of the final and definitive ruling to the commissioner, the
15 legislature, and the Louisiana State Law Institute. The provisions of this
16 Subpart shall become effective ten days after receipt by the commissioner of the
17 written notification.
18 §1123. Preexisting condition exclusions prohibited
19 A health insurance policy or contract issued or issued for delivery in this
20 state after the effective date of this Subpart shall not impose a preexisting
21 condition exclusion. This Section shall not limit an insurer's ability to restrict
22 enrollment in an individual contract to open enrollment and special enrollment
23 periods in accordance with other provisions of this Title.
24 §1124. Annual and lifetime limits prohibited
25 A health insurance policy or contract issued or issued for delivery in this
26 state after the effective date of this Subpart shall not provide any of the
27 following:
28 (1) Establish lifetime limits on the dollar value of benefits for any
29 participant or beneficiary.
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1 (2) Establish annual limits on the dollar value of essential benefits, as
2 determined by the commissioner, to the extent not inconsistent with applicable
3 federal law.
4 §1125. Coverage for dependent children
5 A health insurance policy or contract issued or issued for delivery in this
6 state after the effective date of this Subpart, that offers coverage for a
7 dependent child shall offer dependent coverage, at the option of the
8 policyholder, until the dependent child attains the age of twenty-six. An insurer
9 may require, as a condition of eligibility for coverage in accordance with this
10 Section, that a person seeking coverage for a dependent child provide written
11 documentation on an annual basis that the dependent child satisfies the
12 requirements applicable to dependent children in this Title.
13 §1126. Rate setting
14 For all health insurance policies, contracts, or certificates that are
15 executed, delivered, issued for delivery, continued, or renewed in this state after
16 the effective date of this Subpart, the maximum rate differential due to age filed
17 by the carrier as determined by ratio shall be three to one. The limitation does
18 not apply for determining rates for an attained age of less than nineteen years
19 or more than sixty-five years.
20 §1127. Open enrollment
21 A health insurance policy or contract issued or issued for delivery in this
22 state after the effective date of this Subpart may restrict enrollment in
23 individual health plans to open enrollment periods and special enrollment
24 periods to the extent not inconsistent with applicable federal law. The
25 commissioner may adopt rules establishing minimum open enrollment dates
26 and minimum criteria for special enrollment periods for all individual health
27 plans offered in this state.
28 §1128. Comprehensive health coverage
29 A. Notwithstanding any other provision of law to the contrary, a health
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1 insurance policy or contract issued or issued for delivery in this state thirty days
2 or more after rules promulgated pursuant to Subsection G of this Section
3 become effective shall, at a minimum, provide coverage that incorporates an
4 essential health benefits package consistent with the requirements of this
5 Section.
6 B. As used in this Section, "essential health benefits package" means
7 coverage that:
8 (1) Provides for the essential health benefits defined by the commissioner
9 pursuant to Subsection C of this Section.
10 (2) Limits cost sharing for coverage in accordance with Subsection E of
11 this Section.
12 (3) Provides for levels of coverage in accordance with Subsection F of
13 this Section.
14 C. The commissioner shall ensure that the scope of the essential health
15 benefits package required pursuant to this Section is substantially similar to
16 that of the essential health benefits required for a health plan subject to the
17 federal Patient Protection and Affordable Care Act as of January 1, 2019. The
18 commissioner shall define the essential health benefits required for a health
19 plan, provided the definition includes at a minimum the following general
20 categories and the items and services covered within the categories:
21 (1) Ambulatory patient services.
22 (2) Emergency services.
23 (3) Hospitalization.
24 (4) Maternity and newborn care.
25 (5) Mental health and substance use disorder services, including
26 behavioral health treatment.
27 (6) Prescription drugs.
28 (7) Rehabilitative and habilitative services and devices.
29 (8) Laboratory services.
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1 (9) Preventive and wellness services and chronic disease management.
2 (10) Pediatric services, including oral and vision care.
3 D. In defining essential health benefits for purposes of this Section, the
4 commissioner shall do the following:
5 (1) Ensure that the essential health benefits reflect an appropriate
6 balance among the categories enumerated in Subsection C of this Section, so
7 that benefits are not unduly weighted toward any category.
8 (2) Ensure that coverage decisions, determination of reimbursement
9 rates, establishment of incentive programs, and designation of benefits are
10 effected in ways that do not discriminate against individuals because of age,
11 disability, or life expectancy.
12 (3) Take into account the healthcare needs of diverse segments of the
13 population, including women, children, persons with disabilities, and other
14 groups.
15 (4) Ensure that health benefits established as essential are not subject to
16 denial to an individual against the individual's wishes on the basis of the
17 individual's age or life expectancy or of the individual's present or predicted
18 disability, degree of medical dependency, or quality of life.
19 (5) Provide that a qualified health plan shall not be treated as providing
20 coverage for the essential health benefits package described in Subsection B of
21 this Section unless the plan provides the following:
22 (a) Coverage for emergency department services will be provided
23 without imposing any requirement under the plan for prior authorization of
24 services or any limitation on coverage where the provider of services does not
25 have a contractual relationship with the plan for the providing of services that
26 is more restrictive than the requirements or limitations that apply to emergency
27 department services received from providers who do have such a contractual
28 relationship with the plan.
29 (b) If emergency department services are provided out of network, the
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1 cost sharing requirement, expressed as a copayment amount or coinsurance
2 rate, is the same as the requirement that would apply if the services were
3 provided in network.
4 (6) Provide that if a plan is offered through an exchange, another health
5 plan offered through that exchange shall not fail to be treated as a qualified
6 health plan solely because the plan does not offer coverage of benefits offered
7 through the stand-alone plan that are otherwise required under Paragraph
8 (C)(10) of this Section.
9 (7) Annually review the essential health benefits package under
10 Subsection B of this Section and submit a report to the legislature that contains
11 the following:
12 (a) An assessment of whether enrollees are facing any difficulty accessing
13 needed services for reasons of coverage or cost.
14 (b) An assessment of whether the essential health benefits package needs
15 to be modified or updated to account for changes in medical evidence or
16 scientific advancement.
17 (c) Information on how the essential health benefits package will be
18 modified to address any gaps in access or changes in the evidence base.
19 (d) An assessment of the potential of additional or expanded benefits to
20 increase costs and the interactions between the addition or expansion of benefits
21 and reductions in existing benefits to meet actuarial limitations.
22 (8) Periodically update the essential health benefits package under
23 Subsection B of this Section to address any gaps in access to coverage or
24 changes in the evidence base the commissioner identifies in the review
25 conducted under Paragraph (7) of this Subsection.
26 E. The commissioner shall establish annual limitations on cost sharing
27 and deductibles that are substantially similar to the limitations for health plans
28 subject to the federal Patient Protection and Affordable Care Act as of
29 January 1, 2019. The commissioner may increase the annual limitation as
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1 needed to reflect any premium adjustment percentage. For purposes of this
2 Subsection, "premium adjustment percentage" means the percentage, if any,
3 by which the average per capita premium for health insurance coverage in the
4 United States for the preceding calendar year, as estimated by the commissioner
5 no later than October first of the preceding calendar year, exceeds the average
6 per capita premium for 2019.
7 F. The commissioner shall define levels of coverage that are substantially
8 similar to the levels of coverage required for health plans subject to the federal
9 Patient Protection and Affordable Care Act as of January 1, 2019.
10 G. The commissioner shall promulgate rules pursuant to the
11 Administrative Procedure Act to define "essential health benefits" pursuant to
12 Subsection C of this Section, to establish annual limitations on cost sharing and
13 deductibles pursuant to Subsection E of this Section, and to define required
14 levels of coverage pursuant to Subsection F of this Section.
15 H. Within thirty days of the effective date of rules promulgated that
16 define essential health benefits as required pursuant to Subsection G of this
17 Section or within thirty days after promulgating rules adopting any changes to
18 the definition of essential health benefits, the commissioner shall submit a
19 report summarizing the definition of essential health benefits to the House and
20 Senate committees on insurance.
21 I. This Section shall not be construed to prohibit a health plan from
22 providing benefits in excess of the essential health benefits described in this
23 Section.
24 §1129. Conflict of laws
25 In case of any conflict between the provisions of this Subpart and any
26 other provision of law, the provisions of this Subpart shall control unless
27 application of this Subpart results in a reduction in coverage for any insured.
28 Section 2. This Act shall become effective upon signature by the governor or, if not
29 signed by the governor, upon expiration of the time for bills to become law without signature
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1 by the governor, as provided by Article III, Section 18 of the Constitution of Louisiana. If
2 vetoed by the governor and subsequently approved by the legislature, this Act shall become
3 effective on the day following such approval.
The original instrument and the following digest, which constitutes no part
of the legislative instrument, were prepared by LG Sullivan.
DIGEST
SB 173 Original 2019 Regular Session Mills
Proposed law, which takes effect only after certain delays following a final and definitive
judgment ruling the Patient Protection and Affordable Care Act, P.L. 111-148, (ACA)
unconstitutional, requires every health insurance policy or contract issued or issued for
delivery in this state to adhere to certain standards. Provides for open enrollment, rate
setting, and coverage for dependent children who are under the age of 26. Prohibits
preexisting condition exclusions and annual and lifetime limits.
Proposed law requires the attorney general to notify the commissioner, the legislature, and
the Louisiana State Law Institute if a judgment ruling the ACA unconstitutional becomes
final and definitive. Provides that the provisions of proposed law take effect ten days after
receipt by the commissioner of the notification.
Proposed law requires that health insurance policies cover "essential health benefits".
Charges the commissioner with defining the essential health benefits that are required.
Specifies that the definition shall include certain categories; among these are ambulatory
patient services, emergency services, hospitalization, maternity and newborn care and
pediatric services, mental health services, prescription drugs, and wellness services. Provides
a framework for monitoring, assessing, and updating the definition of essential health
benefits package.
Proposed law requires the commissioner to promulgate rules pursuant to the Administrative
Procedure Act for purposes of implementing proposed law. Requires initial administrative
rules to be adopted before January 1, 2020. Authorizes the commissioner to issue emergency
rules without finding an emergency exists.
Proposed law applies to any health insurance policy or contract issued or issued for delivery
in this state beginning 10 days after the attorney general notifies the commissioner that the
ACA has been ruled unconstitutional.
Proposed law provides that in case of any conflict between the provisions of proposed law
and any other provision of law, the provisions of proposed law shall control unless
application of proposed law results in a reduction in coverage for any insured.
Effective upon signature of the governor or lapse of time for gubernatorial action.
(Adds R.S. 22:11.1 and 1121-1129)
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