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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 self-funded health plans; to provide for prior authorizations; to
4 provide for an annual report; to provide terms, conditions, and procedures; and to
5 provide for 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 for self-funded health plans
9 A. Beginning January 1, 2023 2024, the following applies to self-funded
10 health plans offered by the office:
11 (1) The office shall require every health plan offered through the office to
12 furnish in writing or provide electronically, within one business day of a written or
13 oral request by a healthcare provider, the medical criteria and any other requirements
14 that must be satisfied in order for a particular healthcare service, procedure, or
15 prescription drug to be prior authorized by the health plan. For every self-funded
16 health plan offered through the office, the office shall maintain and publish on
17 a publicly accessible webpage a list of healthcare services, procedures, and
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1 pharmaceuticals subject to prior authorization, including step-therapy and fail-
2 first protocols. The list shall also include the time period allowed for the self-
3 funded health plan to render and communicate a decision and the requirements
4 or criteria that shall be satisfied in order for the plan to prior authorize the
5 healthcare service, procedure, or pharmaceutical. A self-funded health plan
6 offered through the office shall be prohibited from requiring a prior
7 authorization to be obtained for any healthcare service, procedure, or
8 pharmaceutical that is not included on the list published and maintained by the
9 office. A self-funded health plan that fails to render and communicate a prior
10 authorization decision to the requesting healthcare provider within the
11 timeframe published on the list shall cause the healthcare services, procedures,
12 or pharmaceuticals subject to the request to no longer require prior
13 authorization as a condition of payment of the claim.
14 (2) Upon the denial of a prior authorization by a self-funded health plan
15 offered through the office, the office shall require the self-funded health plan to
16 provide with the written notification of the denial either a copy of the applicable law,
17 regulation, policy, procedure, or medical criterion or guideline that was used by the
18 self-funded health plan in the determination to deny the prior authorization or
19 instructions on how to access such law, regulation, policy, procedure, or medical
20 criterion or guideline on the website of the self-funded health plan that is publicly
21 accessible.
22 (3)(a) The office shall make aggregate statistics available on an annual
23 basis, delineated by quarter, for each self-funded health plan offered through
24 the office regarding prior authorization approvals and denials on its website in
25 a readily accessible format. The chief executive officer shall determine the
26 statistics required in order to comply with this Section in accordance with
27 applicable state and federal privacy laws. The statistics shall include but not be
28 limited to the following:
29 (i) The percentage of standard prior authorization requests that were
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1 approved, aggregated for all items and services.
2 (ii) The percentage of standard prior authorization requests that were
3 denied, aggregated for all items and services.
4 (iii) The percentage of standard prior authorization requests that were
5 approved after appeal, aggregated for all items and services.
6 (iv) The percentage of prior authorization requests when the timeframe
7 for review was extended, and the prior authorization request was approved,
8 aggregated for all items and services.
9 (v) The percentage of expedited prior authorization requests that were
10 approved, aggregated for all items and services.
11 (vi) The percentage of expedited prior authorization requests that were
12 denied, aggregated for all items and services.
13 (vii) The average and median time that elapsed between the submission
14 of a request and a determination by the health insurance issuer, for standard
15 prior authorizations, aggregated for all items and services.
16 (viii) The average and median time that elapsed between the submission
17 of a request and a decision by the health insurance issuer for expedited prior
18 authorizations, aggregated for all items and services.
19 (b) The chief executive officer of the office shall submit annually a
20 written report to the Senate Committee on Finance and the House Committee
21 on Appropriations that includes the information required by this Paragraph.
22 * * *
23 Section 2. This Act shall become effective upon signature by the governor or, if not
24 signed by the governor, upon expiration of the time for bills to become law without signature
25 by the governor, as provided by Article III, Section 18 of the Constitution of Louisiana. If
26 vetoed by the governor and subsequently approved by the legislature, this Act shall become
27 effective on the day following such approval.
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The original instrument was prepared by Michelle D. Ridge. The following
digest, which does not constitute a part of the legislative instrument, was
prepared by Tracy Sabina Sudduth.
DIGEST
SB 164 Reengrossed 2023 Regular Session Cloud
Present law provides that the office shall require every self-funded 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 any other
requirements that must be satisfied in order for the service, procedure, or drug to be prior
authorized by the self-funded 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 provides that beginning January 1, 2024, the provisions of proposed law shall
apply to self-funded health plans offered by the office.
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 self-
funded 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 self-funded 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 self-
funded 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 self-funded 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))
Summary of Amendments Adopted by Senate
Senate Floor Amendments to engrossed bill
1. Beginning January 1, 2024, the provisions of proposed law shall apply to
self-funded health plans offered by the office.
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2. Provides that the provisions of proposed law shall only apply to self-funded
health plans.
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Coding: Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions.