SLS 23RS-378 ORIGINAL
2023 Regular Session
SENATE BILL NO. 164
BY SENATOR CLOUD
Prefiled pursuant to Article III, Section 2(A)(4)(b)(i) of the Constitution of Louisiana.
GROUP BENEFITS PROGRAM. Provides relative to prior authorization for services,
procedures, and pharmaceuticals. (gov sig)
1 AN ACT
2 To amend and reenact R.S. 42:812(A), relative to the Office of Group Benefits; to provide
3 for requirements for health plans; to provide for prior authorizations; to provide for
4 an annual report; to provide terms, conditions, and procedures; and to provide for
5 related matters.
6 Be it enacted by the Legislature of Louisiana:
7 Section 1. R.S. 42:812(A) is hereby amended and reenacted to read as follows:
8 ยง812. Transparency in prior authorizations
9 A. Beginning January 1, 2023:
10 (1) The office shall require every health plan offered through the office to
11 furnish in writing or provide electronically, within one business day of a written or
12 oral request by a healthcare provider, the medical criteria and any other requirements
13 that must be satisfied in order for a particular healthcare service, procedure, or
14 prescription drug to be prior authorized by the health plan. For every health plan
15 offered through the office, the office shall maintain and publish on a publicly
16 accessible webpage a list of healthcare services, procedures, and
17 pharmaceuticals subject to prior authorization, including step-therapy and fail
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Coding: Words which are struck through are deletions from existing law;
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1 first protocols. The list shall also include the time period allowed for the health
2 plan to render and communicate a decision and the requirements or criteria
3 that shall be satisfied in order for the plan to prior authorize the healthcare
4 service, procedure, or pharmaceutical. A health plan offered through the office
5 shall be prohibited from requiring a prior authorization to be obtained for any
6 health care service, procedure, or pharmaceutical that is not included on the list
7 published and maintained by the office. A health plan that fails to render and
8 communicate a prior authorization decision to the requesting healthcare
9 provider within the timeframe published on the list shall cause the healthcare
10 services, procedures, or pharmaceuticals subject to the request to no longer
11 require prior authorization as a condition of payment of the claim.
12 (2) Upon the denial of a prior authorization by a health plan offered through
13 the office, the office shall require the health plan to provide with the written
14 notification of the denial either a copy of the applicable law, regulation, policy,
15 procedure, or medical criterion or guideline that was used by the health plan in the
16 determination to deny the prior authorization or instructions on how to access such
17 law, regulation, policy, procedure, or medical criterion or guideline on the website
18 of the health plan that is publicly accessible.
19 (3)(a) The office shall make aggregate statistics available on an annual
20 basis, delineated by quarter, for each health plan offered through the office
21 regarding prior authorization approvals and denials on its website in a readily
22 accessible format. The chief executive officer shall determine the statistics
23 required in order to comply with this Section in accordance with applicable
24 state and federal privacy laws. The statistics shall include but not be limited to
25 the following:
26 (i) The percentage of standard prior authorization requests that were
27 approved, aggregated for all items and services.
28 (ii) The percentage of standard prior authorization requests that were
29 denied, aggregated for all items and services.
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Coding: Words which are struck through are deletions from existing law;
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1 (iii) The percentage of standard prior authorization requests that were
2 approved after appeal, aggregated for all items and services.
3 (iv) The percentage of prior authorization requests when the timeframe
4 for review was extended, and the prior authorization request was approved,
5 aggregated for all items and services.
6 (v) The percentage of expedited prior authorization requests that were
7 approved, aggregated for all items and services.
8 (vi) The percentage of expedited prior authorization requests that were
9 denied, aggregated for all items and services.
10 (vii) The average and median time that elapsed between the submission
11 of a request and a determination by the health insurance issuer, for standard
12 prior authorizations, aggregated for all items and services.
13 (viii) The average and median time that elapsed between the submission
14 of a request and a decision by the health insurance issuer for expedited prior
15 authorizations, aggregated for all items and services.
16 (b) The chief executive officer of the office shall submit annually a
17 written report to the Senate Committee on Finance and the House Committee
18 on Appropriations that includes the information required by this Paragraph.
19 * * *
20 Section 2. This Act shall become effective upon signature by the governor or, if not
21 signed by the governor, upon expiration of the time for bills to become law without signature
22 by the governor, as provided by Article III, Section 18 of the Constitution of Louisiana. If
23 vetoed by the governor and subsequently approved by the legislature, this Act shall become
24 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 Michelle Ridge.
DIGEST
SB 164 Original 2023 Regular Session Cloud
Present law provides that the Office of Group Benefits (office) shall require every health
plan offered through the office to furnish in writing or provide electronically, within one
business day of a written or oral request by a healthcare provider, the medical criteria and
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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. 164
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any other requirements that must be satisfied in order for the service, procedure, or drug to
be prior authorized by the health plan.
Proposed law removes the requirement that in order to receive information relative to prior
authorization requirements for certain services, procedures, or drugs, a healthcare provider
must request the information. Proposed law instead requires that the office maintain and
publish on a publicly accessible webpage a list of healthcare services, procedures, and
pharmaceuticals subject to prior authorization.
Proposed law provides that the list shall also include the time period allowed for the health
plan to render and communicate a decision and the requirements or criteria that shall be
satisfied in order for the plan to prior authorize the healthcare service, procedure, or
pharmaceutical.
Proposed law prohibits a health plan offered through the office from requiring a prior
authorization to be obtained for any healthcare service, procedure, or pharmaceutical that
is not included on the list published and maintained by the office and provides that a health
plan that fails to render and communicate a prior authorization decision to the requesting
healthcare provider within the timeframe published on the list shall cause the healthcare
services, procedures, or pharmaceuticals subject to the request to no longer require prior
authorization as a condition of payment of the claim.
Proposed law requires the office to make aggregate statistics available on an annual basis,
delineated by quarter, for each health plan offered through the office regarding prior
authorization approvals and denials on its website in a readily accessible format. Authorizes
the chief executive officer (CEO) of the office to determine the statistics required in order
to comply with proposed law in accordance with applicable state and federal privacy laws.
Proposed law provides for an illustrative list of statistics required for compliance.
Proposed law requires the CEO to submit the aggregate statistics annually in a written report
to the Senate Committee on Finance and the House Committee on Appropriations.
Effective upon signature of the governor or lapse of time for gubernatorial action.
(Amends R.S. 42:812(A))
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Coding: Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions.