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2019 Regular Session
SENATE BILL NO. 173
BY SENATORS MILLS, APPEL, CHABERT, CLAITOR, CORTEZ, ERDEY, FANNIN,
GATTI, HENSGENS, HEWITT, JOHNS, LONG, MARTINY AND
GARY SMITH
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, 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 1130, and
4 Subpart F-1 of Part III of Chapter 4 of Title 22 of the Louisiana Revised Statutes of
5 1950, to be comprised of R.S. 22:1131 through 1138, relative to health insurance; to
6 provide relative to enrollment, dependent coverage, rate setting, preexisting
7 conditions, annual and lifetime limits, and essential benefits under certain
8 circumstances; to require the commissioner of insurance to establish a risk-sharing
9 program; to provide for the operation, parameters, funding, and legislative approval
10 of the risk-sharing program; to provide for rulemaking; to provide for effectiveness;
11 and to provide for related matters.
12 Be it enacted by the Legislature of Louisiana:
13 Section 1. R.S. 22:11.1, Subpart F of Part III of Chapter 4 of Title 22 of the Louisiana
14 Revised Statutes of 1950, comprised of R.S. 22:1121 through 1130, and Subpart F-1 of Part
15 III of Chapter 4 of Title 22 of the Louisiana Revised Statutes of 1950, comprised of R.S.
16 22:1131 through 1138, are hereby enacted to read as follows:
17 §11.1. Rules and regulations; essential health benefits package
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1 The commissioner shall promulgate rules pursuant to the Administrative
2 Procedure Act to define "essential health benefits", to establish annual
3 limitations on cost sharing and deductibles, and to define required levels of
4 coverage. The commissioner shall adopt initial administrative rules before
5 January 1, 2020. Notwithstanding any provision of R.S. 49:953(B) to the
6 contrary, the commissioner may adopt initial administrative rules as required
7 by this Section pursuant to the provisions of R.S. 49:953(B) without a finding
8 that an imminent peril to the public health, safety, or welfare exists.
9 * * *
10 SUBPART F. HEALTHCARE COVERAG E FOR LOUISIANA
11 FAMILIES PROTECTION ACT
12 §1121. Short Title
13 This Subpart shall be known and may be cited as the "Healthcare
14 Coverage for Louisiana Families Protection Act".
15 §1122. Effectiveness
16 If a court of competent jurisdiction rules that the Patient Protection and
17 Affordable Care Act, P.L. 111-148, is unconstitutional and the judgment of that
18 court becomes final and definitive, the attorney general shall give written
19 notification of the final and definitive ruling to the commissioner, the
20 legislature, and the Louisiana State Law Institute. The provisions of this
21 Subpart shall become effective ninety days after receipt by the commissioner of
22 the written notification. However, no provision of this Subpart shall abridge or
23 affect the provisions of insurance policies or contracts already in effect until
24 such policies or contracts are renewed.
25 §1123. Preexisting condition exclusions prohibited
26 A health insurance policy or contract issued or issued for delivery in this
27 state after the effective date of this Subpart shall not impose a preexisting
28 condition exclusion. This Section shall not limit an insurer's ability to restrict
29 enrollment in an individual contract to open enrollment and special enrollment
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1 periods in accordance with other provisions of this Title.
2 §1124. Annual and lifetime limits prohibited
3 A health insurance policy or contract issued or issued for delivery in this
4 state after the effective date of this Subpart shall not do either of the following:
5 (1) Establish lifetime limits on the dollar value of benefits for any
6 participant or beneficiary.
7 (2) Establish annual limits on the dollar value of essential benefits, as
8 determined by the commissioner, to the extent not inconsistent with applicable
9 federal law.
10 §1125. Coverage for dependent children
11 A health insurance policy or contract issued or issued for delivery in this
12 state after the effective date of this Subpart that offers coverage for a dependent
13 child shall offer dependent coverage, at the option of the policyholder, until the
14 dependent child attains the age of twenty-six. An insurer may require, as a
15 condition of eligibility for coverage in accordance with this Section, that a
16 person seeking coverage for a dependent child provide written documentation
17 on an annual basis that the dependent child satisfies the requirements
18 applicable to dependent children in this Title.
19 §1126. Rate setting
20 For all health insurance policies, contracts, or certificates that are
21 executed, delivered, issued for delivery, continued, or renewed in this state after
22 the effective date of this Subpart, the maximum rate differential due to age filed
23 by the carrier as determined by ratio shall be five to one. The limitation does
24 not apply for determining rates for an attained age of less than nineteen years
25 or more than sixty-five years.
26 §1127. Open enrollment
27 A health insurance policy or contract issued or issued for delivery in this
28 state after the effective date of this Subpart may restrict enrollment in
29 individual health plans to open enrollment periods and special enrollment
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1 periods to the extent not inconsistent with applicable federal law. The
2 commissioner may adopt rules establishing minimum open enrollment dates
3 and minimum criteria for special enrollment periods for all individual health
4 plans offered in this state.
5 §1128. Comprehensive health coverage
6 A. Notwithstanding any other provision of law to the contrary, a health
7 insurance policy or contract issued or issued for delivery in this state thirty days
8 or more after rules promulgated pursuant to Subsection G of this Section
9 become effective shall, at a minimum, provide coverage that incorporates an
10 essential health benefits package consistent with the requirements of this
11 Section.
12 B. As used in this Section, "essential health benefits package" means
13 coverage that:
14 (1) Provides for the essential health benefits defined by the commissioner
15 pursuant to Subsection C of this Section.
16 (2) Limits cost sharing for coverage in accordance with Subsection E of
17 this Section.
18 (3) Provides for levels of coverage in accordance with Subsection F of
19 this Section.
20 C. The commissioner shall ensure that the scope of the essential health
21 benefits package required pursuant to this Section is substantially similar to
22 that of the essential health benefits required for a health plan subject to the
23 federal Patient Protection and Affordable Care Act as of January 1, 2019. The
24 commissioner shall define the essential health benefits required for a health
25 plan, provided the definition includes at a minimum the following general
26 categories and the items and services covered within the categories:
27 (1) Ambulatory patient services.
28 (2) Emergency services.
29 (3) Hospitalization.
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1 (4) Maternity and newborn care.
2 (5) Mental health and substance use disorder services, including
3 behavioral health treatment.
4 (6) Prescription drugs.
5 (7) Rehabilitative and habilitative services and devices.
6 (8) Laboratory services.
7 (9) Preventive and wellness services and chronic disease management.
8 (10) Pediatric services, including oral and vision care.
9 D. In defining essential health benefits for purposes of this Section, the
10 commissioner shall do the following:
11 (1) Ensure that the essential health benefits reflect an appropriate
12 balance among the categories enumerated in Subsection C of this Section, so
13 that benefits are not unduly weighted toward any category.
14 (2) Ensure that coverage decisions, determination of reimbursement
15 rates, establishment of incentive programs, and designation of benefits are
16 effected in ways that do not discriminate against individuals because of age,
17 disability, or life expectancy.
18 (3) Take into account the healthcare needs of diverse segments of the
19 population, including women, children, persons with disabilities, and other
20 groups.
21 (4) Ensure that health benefits established as essential are not subject to
22 denial to an individual, against the individual's wishes, on the basis of the
23 individual's age or life expectancy or of the individual's present or predicted
24 disability, degree of medical dependency, or quality of life.
25 (5) Provide that a qualified health plan shall not be treated as providing
26 coverage for the essential health benefits package described in Subsection B of
27 this Section unless the plan complies with the provisions of the Patient
28 Protection and Affordable Care Act, P. L. 111-148, relative to coverage and
29 payment for emergency department services.
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1 (6) Provide that if a plan is offered through an exchange, another health
2 plan offered through that exchange shall not fail to be treated as a qualified
3 health plan solely because the plan does not offer coverage of benefits offered
4 through the stand-alone plan that are otherwise required under Paragraph
5 (C)(10) of this Section.
6 (7) Annually review the essential health benefits package under
7 Subsection B of this Section and submit a report to the legislature that contains
8 the following:
9 (a) An assessment of whether enrollees are facing any difficulty accessing
10 needed services for reasons of coverage or cost.
11 (b) An assessment of whether the essential health benefits package needs
12 to be modified or updated to account for changes in medical evidence or
13 scientific advancement.
14 (c) Information on how the essential health benefits package will be
15 modified to address any gaps in access or changes in the evidence base.
16 (d) An assessment of the potential of additional or expanded benefits to
17 increase costs and the interactions between the addition or expansion of benefits
18 and reductions in existing benefits to meet actuarial limitations.
19 (8) Periodically update the essential health benefits package under
20 Subsection B of this Section to address any gaps in access to coverage or
21 changes in the evidence base the commissioner identifies in the review
22 conducted under Paragraph (7) of this Subsection.
23 E. The commissioner shall establish annual limitations on cost sharing
24 and deductibles that are substantially similar to the limitations for health plans
25 subject to the federal Patient Protection and Affordable Care Act as of
26 January 1, 2019. The commissioner may increase the annual limitation as
27 needed to reflect any premium adjustment percentage. For purposes of this
28 Subsection, "premium adjustment percentage" means the percentage, if any,
29 by which the average per capita premium for health insurance coverage in the
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1 United States for the preceding calendar year, as estimated by the commissioner
2 no later than October first of the preceding calendar year, exceeds the average
3 per capita premium for 2019.
4 F. The commissioner shall define levels of coverage that are substantially
5 similar to the levels of coverage required for health plans subject to the federal
6 Patient Protection and Affordable Care Act as of January 1, 2019.
7 G. The commissioner shall promulgate rules pursuant to the
8 Administrative Procedure Act to define "essential health benefits" pursuant to
9 Subsection C of this Section, to establish annual limitations on cost sharing and
10 deductibles pursuant to Subsection E of this Section, and to define required
11 levels of coverage pursuant to Subsection F of this Section.
12 H. Within thirty days of the effective date of rules promulgated that
13 define essential health benefits as required pursuant to Subsection G of this
14 Section or within thirty days after promulgating rules adopting any changes to
15 the definition of essential health benefits, the commissioner shall submit a
16 report summarizing the definition of essential health benefits to the House and
17 Senate committees on insurance.
18 I. This Section shall not be construed to prohibit a health plan from
19 providing benefits in excess of the essential health benefits described in this
20 Section.
21 §1129. Conflict of laws
22 In case of any conflict between the provisions of this Subpart and any
23 other provision of law, the provisions of this Subpart shall control unless
24 application of this Subpart results in a reduction in coverage for any insured.
25 §1130. Applicability
26 A. The provisions of this Subpart shall be effective or enforceable only
27 in the event that the tax credit authorized in Section 1401 of the Patient
28 Protection and Affordable Care Act of 2010, P. L. 111-148, as amended by the
29 Healthcare and Education Reconciliation Act of 2010, P. L. 111-152, and
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1 codified in Section 16B of the Internal Revenue Code, is held to be valid by a
2 court of competent jurisdiction or is otherwise enforceable at law, or unless
3 adequate appropriations are timely made by the federal or state government in
4 an amount that is calculated in a similar manner as the tax credit in Section
5 1401 of the Patient Protection and Affordable Care Act.
6 B. The provisions of this Subpart shall not apply to grandfathered
7 coverage as defined in R.S. 22:1091(B)(4).
8 C. The provisions of this Subpart shall not apply to health benefit plans
9 in the large groups as defined in R.S. 22:1091(B)(13) or to the large group
10 market as defined in R.S. 22:1091(B)(14).
11 D. The provisions of this Subpart shall not apply to limited or excepted
12 benefits policies as defined in this Title.
13 SUBPART F-1. LOUISIANA GUARANTEED BENEF ITS POOL
14 §1131. Short title
15 This Subpart shall be known and may be cited as the "Louisiana
16 Guaranteed Benefits Pool Act".
17 §1132. Definitions
18 As used in this Subpart, the following definitions apply:
19 (1) "Commissioner" means the commissioner of insurance.
20 (2) "Program" means the Louisiana Guaranteed Benefits Pool.
21 §1133. Louisiana Guaranteed Benefits Pool; establishment
22 A. The commissioner shall establish the Louisiana Guaranteed Benefits
23 Pool which shall be a risk-sharing program to provide payment to health
24 insurance issuers for claims for healthcare services provided to eligible
25 individuals with expected high healthcare costs for the purpose of lowering
26 premiums for health insurance coverage offered in the individual market.
27 B. In establishing the program, the commissioner shall do all of the
28 following:
29 (1) Examine Louisiana's historical experience with the Louisiana Health
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1 Plan high risk pool, R.S. 22:1201 et seq.
2 (2) Consult with healthcare consumers, health insurance issuers, and
3 other interested stakeholders.
4 (3) Take into consideration high-cost health conditions and other health
5 trends that generate a high cost.
6 §1134. Operation of program
7 A. The commissioner shall establish the Louisiana Guaranteed Benefits
8 Pool with a framework and operation similar to other state best practices.
9 B. The program may be administered by either the commissioner or by
10 an independent nonprofit organization.
11 §1135. Actuarial analysis
12 In establishing the program, the commissioner shall commission an
13 actuarial analysis to do all of the following:
14 (1) Inform the development and parameters of the program.
15 (2) Evaluate how funds that may currently be utilized to pay the Health
16 Insurance Provider Fee (HIPF) or may be recovered pursuant to litigation
17 related to the HIPF may be used to contribute to the funding of the guaranteed
18 benefits pool.
19 (3) Estimate the necessary funding required to reach the premium
20 reduction goals of the program, taking into consideration all of the above-listed
21 sources.
22 §1136. Program parameters
23 In establishing the program, the commissioner shall provide for all of the
24 following:
25 (1) The criteria for individuals to be eligible for participation in the
26 program.
27 (2) The development and use of health status statements with respect to
28 eligible individuals.
29 (3) The standards for qualification, including but not limited to all of the
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1 following:
2 (a) The identification of health conditions that automatically qualify
3 individuals as eligible individuals at the time of application for health insurance
4 coverage.
5 (b) A process pursuant to which health insurance issuers may voluntarily
6 qualify individuals who do not automatically qualify as eligible individuals at
7 the time of application for coverage.
8 (4) The percentage of the premiums paid to health insurance issuers for
9 health insurance coverage by eligible individuals that shall be collected and
10 deposited to the credit and available for the use of the program.
11 (5) The threshold dollar amount of claims for eligible individuals after
12 which the program will provide payments to health insurance issuers and the
13 proportion of the claims above the threshold dollar amount that the program
14 will pay.
15 §1137. Approval by legislature
16 A. The commissioner shall submit the actuarial analysis required by R.S.
17 22:1135 to the Joint Legislative Committee on the Budget.
18 B. The Joint Legislative Committee on the Budget shall meet to review
19 and approve the actuarial analysis, the details of the program as determined by
20 the commissioner, and any required funding. The committee may also take any
21 other action with respect to the program deemed necessary by the committee.
22 §1138. Enrollment or participation limitation
23 The commissioner shall not enroll an individual or permit any individual
24 to participate as an eligible individual in the program unless the commissioner
25 has received written notification from the attorney general of a final and
26 definitive ruling by a court of competent jurisdiction that the federal Patient
27 Protection and Affordable Care Act, P.L. 111-148, is unconstitutional pursuant
28 to R.S. 22:1122.
29 Section 2.(A) The commissioner of insurance shall take all such actions as are
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1 necessary to commission the actuarial analysis required by R.S. 22:1135, as enacted by
2 Section 1 of this Act, before August 1, 2019.
3 (B) The commissioner of insurance shall submit the actuarial analysis as required by
4 R.S. 22:1137, as enacted by Section 1 of this Act, and shall submit a report containing a
5 detailed description of the proposed Louisiana Guaranteed Benefits Pool program to the
6 Joint Legislative Committee on the Budget on or before March 1, 2020.
7 (C) Upon receipt of the actuarial analysis and report, the Joint Legislative Committee
8 on the Budget shall meet at the next available opportunity to review and approve the
9 actuarial analysis, the details of the program as determined by the commissioner, and any
10 required funding pursuant to R.S. 22:1137, as enacted by Section 1 of this Act.
11 Section 3. This Act shall become effective upon signature by the governor or, if not
12 signed by the governor, upon expiration of the time for bills to become law without signature
13 by the governor, as provided by Article III, Section 18 of the Constitution of Louisiana. If
14 vetoed by the governor and subsequently approved by the legislature, this Act shall become
15 effective on the day following such approval.
The original instrument was prepared by LG Sullivan. The following digest,
which does not constitute a part of the legislative instrument, was prepared
by Tammy Crain Waldrop.
DIGEST
SB 173 Reengrossed 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 ninety 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.
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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 ninety days after final judgment of a court of competent jurisdiction on
the constitutionality of ACA. 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 ninety days after the attorney general notifies the commissioner that
the ACA has been ruled unconstitutional. Proposed law does not abridge or affect the
provisions of insurance policies or contracts already in effect until the policies or contracts
are renewed.
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.
Proposed law provides that applicability of proposed law shall occur only if the current
federal tax credit is held to be valid by a court of competent jurisdiction or is otherwise
enforceable at law, or unless adequate appropriations are timely made by the federal or state
government in an amount that is calculated in the same manner as the tax credit in Section
1401 of the Patient Protection and Affordable Care Act.
Proposed law provides that it shall not apply to grandfathered coverage, health benefit plans
in the large groups or to the large group market, or to limited or excepted benefits policies
as defined in present law.
Proposed law establishes the "Louisiana Guaranteed Benefits Pool" to be administered by
the commissioner of insurance which shall be a risk-sharing program to provide payment to
health insurance issuers for claims for healthcare services provided to eligible individuals
with expected high healthcare costs for the purpose of lowering premiums for health
insurance coverage offered in the individual market.
Proposed law establishes program operations and parameters, actuarial analysis, approval
of the program by the Joint Legislative Committee on the Budget, and enrollment or
participation limitations.
Effective upon signature of the governor or lapse of time for gubernatorial action.
(Adds R.S. 22:11.1 and 1121-1138)
Summary of Amendments Adopted by Senate
Committee Amendments Proposed by Senate Committee on Health and Welfare to
the original bill
1. Changes Louisiana Department of Insurance rulemaking deadline from
January 1,2020, to ninety days after final judgment of a court of competent
jurisdiction on the constitutionality of ACA.
2. Changes effective date from ten to ninety days after receipt by the
commissioner of the written notification of the court's ruling in ACA.
3. Provides that proposed law does not abridge or affect the provisions of
insurance policies or contracts already in effect until the policies or contracts
are renewed.
4. Changes the ratio for rate setting from three to one to five to one.
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5. Clarifies that the emergency department services provisions shall comply
with those established in ACA for coverage and payment of services.
6. Provides that applicability of proposed law shall occur only if the current
federal tax credit is held to be valid by a court of competent jurisdiction or
is otherwise enforceable at law, or unless adequate appropriations are timely
made by the federal or state government in an amount that is calculated in the
same manner as the tax credit in Section 1401 of the Patient Protection and
Affordable Care Act.
7. Proposed law provides that it shall not apply to grandfathered coverage,
health benefit plans in the large groups or to the large group market, or to
limited or excepted benefits policies as defined in present law.
8. Provides for an assessment by the commissioner of insurance on nationwide
individual insurance market cost stabilization programs and a report to the
Legislature with findings and recommendations by March 1, 2020.
9. Establishes the "Louisiana Guaranteed Benefits Pool" to be administered by
the commissioner of insurance which shall be a risk-sharing program to
provide payment to health insurance issuers for claims for healthcare services
provided to eligible individuals with expected high healthcare costs for the
purpose of lowering premiums for health insurance coverage offered in the
individual market.
Senate Floor Amendments to engrossed bill
1. Makes technical amendment changes.
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