reglab/statecodes huggingface dataset:
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1035. Inherited metabolic diseases; coverage for food products

RS 22:1035 - Inherited metabolic diseases; coverage for food products
A. Any health, hospital, or medical expense insurance policy, hospital or medical service contract, employee welfare benefit plan, health and accident insurance policy, or any other insurance contract of this type, including a group insurance plan, and a self-insurance plan that provides medical and surgical benefits, which is delivered, issued for delivery, or renewed in this state on or after January 1, 2002, shall provide coverage, subject to applicable deductibles, coinsurance, and copayments, for low protein food products for treatment of inherited metabolic diseases, if the low protein food products are medically necessary and, if applicable, are obtained from a source approved by the health insurance issuer, provided coverage will not be denied if the health insurance issuer does not approve a source.
B. As used in this Section, the following words shall have the following meanings:
(1) "Inherited metabolic disease" shall mean a disease caused by an inherited abnormality of body chemistry. Such diseases shall be limited to:
(a) Glutaric Acidemia.
(b) Isovaleric Acidemia (IVA).
(c) Maple Syrup Urine Disease (MSUD).
(d) Methylmalonic Acidemia (MMA).
(e) Phenylketonuria (PKU).
(f) Propionic Acidemia.
(g) Tyrosinemia.
(h) Urea Cycle Defects.
(2) "Low protein food products" shall mean a food product that is especially formulated to have less than one gram of protein per serving and is intended to be used under the direction of a physician for the dietary treatment of an inherited metabolic disease. Low protein food products shall not include a natural food that is naturally low in protein.
C. Coverage provided pursuant to this Section shall not exceed eligible benefits of two hundred dollars per month.
D. The provisions of this Section shall not apply to limited benefit and short-term health insurance policies or contracts.
Acts 2001, No. 1013, §1; Redesignated from R.S. 22:215.22 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009; Acts 2010, No. 919, §1, eff. Jan. 1, 2011.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1036. Prohibited exclusion of coverage of correctable medical conditions on basis of infertility

RS 22:1036 - Prohibited exclusion of coverage of correctable medical conditions on basis of infertility
A.(1) Any health insurance policy, contract, or plan specified in Subsection B of this Section which is issued for delivery, delivered, renewed, or otherwise contracted for in this state on or after January 1, 2002, shall not exclude coverage for diagnosis and treatment of a correctable medical condition otherwise covered by the policy, contract, or plan solely because the condition results in infertility.
(2) This Section shall not be construed to require coverage of the following:
(a) Fertility drugs.
(b) In vitro fertilization or any other assisted reproductive technique.
(c) Reversal of a tubal ligation, a vasectomy, or any other method of sterilization.
B. As used in this Section, a health insurance policy, contract, or plan shall include any hospital, health, or medical expense insurance policy, hospital or medical service contract, employee welfare benefit plan, contract or agreement with a health maintenance organization or a preferred provider organization, health and accident insurance policy, or any other insurance contract of this type, including a group insurance plan, a self-insurance plan, and the Office of Group Benefits programs.
Acts 2001, No. 1045, §1; Redesignated from R.S. 22:215.23 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1037. Health insurance coverage for activities performed by a registered nurse first assistant

RS 22:1037 - Health insurance coverage for activities performed by a registered nurse first assistant
A. Any hospital, health, or medical expense insurance policy, hospital or medical service contract, employee welfare benefit plan, health maintenance organization subscriber agreement, health and accident insurance policy, or any other insurance contract of this type, including a group insurance plan and a self-insurance plan that provides medical and surgical benefits which are delivered, issued for delivery, or renewed in this state on or after January 1, 2004, shall not deny coverage of perioperative services rendered by a registered nurse first assistant if the insurer covers the same such first assistant perioperative services when they are rendered by an advanced practice nurse, a physician assistant, or a physician other than the operating surgeon. Payments to registered nurse first assistants for such services shall be subject to the same credentialing and contracting requirements that apply to other health care providers paid for such services.
B. The provisions of this Section shall not apply to limited benefit health insurance policies or contracts authorized to be issued in this state. Additionally, the provisions of this Section shall not be construed to prohibit or prevent a health insurer or health maintenance organization from conducting a utilization review pertaining to coverage of the services of a registered nurse first assistant.
C. As used in this Section:
(1) "Perioperative services" means preoperative, intraoperative, and postoperative nursing care provided to surgical patients.
(2) "Recognized program" means a program that addresses all content of the core curriculum for registered nurse first assistant as established by the Association of Operating Room Nurses or its successor organization.
(3) "Registered nurse first assistant" means a person who has met all of the following requirements:
(a) Is licensed as a registered nurse in accordance with state law.
(b) Is experienced in perioperative nursing.
(c) Has successfully completed a recognized program.
Acts 2003, No. 190, §1; Redesignated from R.S. 22:215.24 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009; Acts 2010, No. 919, §1, eff. Jan. 1, 2011.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1039. Surgical services; place of service

RS 22:1039 - Surgical services; place of service
Any insurer of any policy of health and accident insurance issued or having effect in this state, shall pay any claim up to the limit of the policy for any service performed in a licensed ambulatory surgical center as defined in R.S. 40:2133A, providing such service would have been covered if performed as an inpatient service.
Added by Acts 1977, No. 350, §1; Redesignated from R.S. 22:223 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1040. Coverage for dental procedures; anesthesia and hospitalization

RS 22:1040 - Coverage for dental procedures; anesthesia and hospitalization
A. Every hospital, health, or medical expense insurance policy, hospital or medical service contract, employee welfare benefit plan, health and accident insurance policy, or any policy of group, family group, blanket, or association health and accident insurance, a self-insurance plan, health maintenance organization, and preferred provider organization, and the Office of Group Benefits programs, which are delivered or issued for delivery in this state shall provide benefits for anesthesia when rendered in a hospital setting and for associated hospital charges when the mental or physical condition of the insured requires dental treatment to be rendered in a hospital setting.
B. An insurer under this Section may require prior authorization for hospitalization for dental care procedures in the same manner that prior authorization is required for hospitalization for other covered medical conditions. For a patient to satisfy the criteria of Subsection A of this Section, a dentist shall consider the Indications for General Anesthesia, as published in the reference manual of the American Academy of Pediatric Dentistry, as utilization standards for determining whether performing dental procedures necessary to treat the particular condition or conditions of the patient under general anesthesia constitutes appropriate treatment.
C. The provisions of this Section shall not apply to treatment rendered for temporal mandibular joint (TMJ) disorders.
D. An insurer under this Section may restrict coverage to include only procedures performed by:
(1) A fully accredited specialist in pediatric dentistry or other dentists fully accredited in a recognized dental specialty for which hospital privileges are granted.
(2) A dentist who is certified by virtue of completion of an accredited program of post-graduate hospital training to be granted hospital privileges.
(3) A dentist who has not yet satisfied the certification requirements, but has been granted hospital privileges as of January 1, 1998.
E. The provisions of this Section shall not apply to limited benefit health insurance policies or contracts authorized to be issued in this state.
Acts 1997, No. 1125, §1, eff. Jan. 1, 1998; Acts 1999, No. 1188, §1; Acts 2001, No. 1178, §2, eff. June 29, 2001; Acts 2003, No. 129, §1, eff. May 28, 2003; Redesignated from R.S. 22:228.7 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009; Acts 2010, No. 919, §1, eff. Jan. 1, 2011.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1041. Discrimination against recovered or rehabilitated alcoholics; prohibited

RS 22:1041 - Discrimination against recovered or rehabilitated alcoholics; prohibited
No insurer doing business in the state that issues an individual or group policy of hospitalization or major medical coverage shall discriminate against any person solely on the basis that he is a recovered or rehabilitated alcoholic by denial of coverage or benefits, assessment or collection of higher premiums, or cancellation of the policy. The insurer, at its own costs, may require that the person submit to reasonable medical testing to determine the diagnosis of the person as an alcoholic. This Section shall not prohibit the underwriting of health conditions which arise from alcoholism. The provisions of this Section shall not apply to individually underwritten, guaranteed renewable or renewable limited benefit supplemental health insurance policies authorized to be issued in this state or to medical benefit plans that are established under and regulated by the Employment Retirement Income Security Act of 1974.
Acts 1997, No. 1481, §1; Redesignated from R.S. 22:1041 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1041.1. Smoking cessation benefits; coverage

RS 22:1041.1 - Smoking cessation benefits; coverage
A.(1) Any health coverage plan delivered or issued for delivery in this state shall include coverage for smoking cessation benefits for a minimum period of six months if a licensed physician recommends and certifies that the smoking cessation benefits may help the person to quit smoking.
(2) The coverage required in this Section shall not be subject to annual deductibles, coinsurance, copayment, or any other out-of-pocket or cost-sharing expense provisions.
B. For purposes of this Section, the following definitions apply:
(1) "Health coverage plan" means any hospital, health, or medical expense insurance policy, hospital or medical service contract, employee welfare benefit plan, contract, or other agreement with a health maintenance organization or a preferred provider organization, health and accident insurance policy, or any other insurance contract of this type in this state, including a group insurance plan, a self-insurance plan, and the Office of Group Benefits programs. "Health coverage plan" shall not include a plan providing coverage for excepted benefits as defined in R.S. 22:1061, limited benefit health insurance plans, and short-term policies that have a term of less than twelve months.
(2) "Smoking cessation benefits" means smoking cessation treatments and services, including individual counseling, group counseling, nicotine patches, nicotine gum, nicotine lozenges, nicotine nasal spray, nicotine inhaler, bupropion, and varenicline.
Acts 2023, No. 281, §1.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1042. Coverage for rehabilitative physical therapy, occupational therapy, and speech and language pathology therapy; optional coverage

RS 22:1042 - Coverage for rehabilitative physical therapy, occupational therapy, and speech and language pathology therapy; optional coverage
A. Each group, family group, blanket, or association health and accident insurance policy including any insurance program, except the Office of Group Benefits programs, covering the state of Louisiana or any of its subdivisions, departments, or agencies or any of the governing boards or authorities of any state university or college or any public elementary or secondary school system, which is delivered or issued for delivery in this state shall include as an option to be exercised by the policyholder, as defined therein, covered benefits for speech and language pathology therapy, physical therapy, rehabilitative services, and occupational therapy. As an alternative to offering optional coverage, including these benefits as standard benefits in such policies and programs shall be sufficient to comply with the requirements of this Subsection.
B. These benefits shall be payable when the rehabilitative treatment or services are rendered by a licensed speech pathologist or licensed audiologist in the case of speech or language therapy, or by a licensed physical therapist in the case of physical therapy, or when the rehabilitative treatment or services are rendered by a physician licensed in this state, or when such treatment or services are rendered by a licensed occupational therapist or by a licensed chiropractor.
C. The effective date for policies, contracts, programs, or plans specified in Subsection A of this Section shall be as provided herein. The provisions of this Section shall apply to all new policies, contracts, programs, or plans issued on or after January 1, 1991. Any policies, contracts, or plans in effect on December 31, 1990, shall, on the anniversary date of such coverage, be covered in accordance with this Section; however, all existing policies shall be converted to conform to the provisions of this Section no later than January 1, 1992.
Acts 1990, No. 1071, §1; Acts 1991, No. 761, §1; Acts 1993, No. 703, §1; Acts 2001, No. 1178, §2, eff. June 29, 2001; Acts 2003, No. 129, §1, eff. May 28, 2003; Acts 2008, No. 151, §1; Redesignated from R.S. 22:230.1 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009; Acts 2008, No. 529, §1, eff. June 30, 2008.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1045. Group, blanket, and association health and accident insurance; continuation of coverage

RS 22:1045 - Group, blanket, and association health and accident insurance; continuation of coverage
A. Each group, blanket, or association insurance policy containing provisions for payment by the insurer of benefits for expenses incurred for hospital, nursing, medical, or surgical services, issued or renewed in this state on or after September 9, 1983, shall include within its provisions the following:
(1) An option for all surviving spouses, that are fifty years of age or greater, of deceased employees covered by the group plan by virtue of their family relationship to a group member to continue as a member of the group plan when their eligibility for group coverage ceases due to death of the employee-member.
(2) The continuation option provided for above shall not be conditioned upon any physical examination.
(3) The continuation option shall entitle the surviving spouse to coverage identical in scope to that provided for under the group plan.
(4) The policyholder shall be responsible for billing and collection of the premium; however, the premium amount shall not exceed the premium assessed for each group member under the group insurance policy. The premium shall be based upon the community costs of the pool of members of the group insurance policy, family members, or dependents covered under the group policy.
(5) The surviving spouse shall have ninety days after the date of death to notify the insurer that the continuation option will be exercised. Coverage under the group insurance plan shall not be terminated during the ninety day notification period. No probationary or waiting period shall be required.
(6) If the continuation option is exercised, coverage of the surviving spouse under the group plan shall continue without interruption and may not be terminated, unless one of the following occurs:
(a) The insured fails to make timely payment of the required premium amount.
(b) The insured becomes eligible for Medicare benefits.
(c) The insured becomes eligible to participate in another group health and accident insurance plan.
(d) The insured remarries.
B. If the insurer has been furnished with the home address of the surviving spouse and has been notified of the death of the employee by the policy owner, the insurer shall notify the surviving spouse of the right to the continuation option.
C. This Section shall not be construed to interfere with or diminish any protection already provided pursuant to collective bargaining agreements and employer-sponsored plans that are more favorable to the surviving spouses benefited thereby than the protection offered by this Section.
Added by Acts 1983, No. 513, §1; Acts 2003, No. 129, §1, eff. May 28, 2003; Redesignated from R.S. 22:215.7 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1051. Benefits for certain services provided by a licensed marriage and family therapist

RS 22:1051 - Benefits for certain services provided by a licensed marriage and family therapist
A. Notwithstanding any contrary provision of a health coverage plan specified in Subsection C of this Section which is issued for delivery, delivered, renewed, or otherwise contracted for in this state on or after January 1, 2009, whenever such plan provides benefits for health-related services that can be lawfully performed by a marriage and family therapist licensed under the provisions of R.S. 37:1101 et seq., the insured or other person entitled to benefits under such health coverage plan shall be entitled to benefits for such services performed by a licensed marriage and family therapist. In order for a policyholder or covered dependent to be eligible for in-network benefits and for a health care provider to be reimbursed directly by a health insurance issuer, such health care provider shall meet a health insurance issuer's contracting and credentialing requirements. Nothing in this Section shall be construed to mean that any health coverage plan is required to include benefits for any additional services.
B. The provisions of this Section shall apply only to those services which a licensed marriage and family therapist is authorized to perform under the provisions of R.S. 37:1101 et seq.
C. As used in this Section, "health coverage plan" means any hospital, health, or medical expense insurance policy, hospital or medical service contract, employee welfare benefit plan, contract, or other agreement with a health maintenance organization or a preferred provider organization, health and accident insurance policy, or any other insurance contract of this type in this state, including a group insurance plan, a self-insurance plan, and the Office of Group Benefits programs.
Acts 2008, No. 305, §1.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1052. Exemption from health insurance mandates

RS 22:1052 - Exemption from health insurance mandates
Notwithstanding any other provision of this Title to the contrary and not unless otherwise specifically provided in an act of the legislature, the provisions of this Subpart shall not apply to limited benefit health insurance policies or contracts, as defined by R.S. 22:47(2)(c).
Acts 2010, No. 549, §1.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1054. Requirement for access to coverage for individuals diagnosed with a terminal condition

RS 22:1054 - Requirement for access to coverage for individuals diagnosed with a terminal condition
A. Notwithstanding any other provision of the law to the contrary and particularly the provisions of R.S. 22:1047, no health care coverage plan shall deny coverage for medically necessary treatment prescribed by a physician and agreed to by a fully informed insured or, if the insured lacks legal capacity to consent, by a person who has legal authority to consent on the insured's behalf, based solely on an insured's life expectancy or the fact that the insured is diagnosed with a terminal condition.
B. Refusing coverage for medically necessary treatment to be rendered to an insured based solely on the insured's life expectancy or the fact that the insured is diagnosed with a terminal condition shall be a violation of this Section.
C.(1) As used in this Section, "terminal condition" means any malignancy or chronic end-stage cardiovascular or cerebral vascular disease that is likely to result in the insured's death.
(2) As used in this Section, "health coverage plan" means any hospital, health or medical insurance policy, hospital or medical service contract, employee welfare benefit plan, contract or agreement with a health maintenance organization or a preferred provider organization, health and accident insurance policy, or any other insurance contract of this type, including a group insurance plan and the Office of Group Benefits programs.
Acts 2014, No. 541, §1, eff. June 5, 2014.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1054.1. Requirement for coverage of cancer treatment targeting a specific genetic mutation

RS 22:1054.1 - Requirement for coverage of cancer treatment targeting a specific genetic mutation
A. No health coverage plan delivered or issued for delivery in this state shall deny coverage for the treatment of metastatic or unresectable tumors or other advanced cancers with a medically necessary drug prescribed by a physician on the basis that the drug is not indicated for the specific tumor type or location in the body of the patient's cancer if the drug is approved by the United States Food and Drug Administration for the treatment of the specific mutation in a different type of cancer. Insurers shall not consider the treatment experimental or outside of their policy scope if the United States Food and Drug Administration has approved the drug for the treatment of cancer with the specific genetic mutation, even if in a different tumor type. This coverage may be denied only if an alternative treatment has proven to be more effective in published randomized clinical trials and is not contraindicated in the patient.
B.(1) Any health coverage plan delivered or issued for delivery in this state shall include coverage for a minimum initial treatment period of not less than three months for a medically necessary drug prescribed by a physician that is not indicated for the location in the body of the patient's cancer if the drug is approved by the United States Food and Drug Administration for the treatment of the specific mutation of the patient's cancer.
(2) The health coverage plan shall continue to provide coverage of the prescribed drug after the initial treatment period provided for in Paragraph (1) of this Subsection if the treating physician certifies that the prescribed drug is medically necessary for the treatment of the patient's cancer based on documented improvement of the patient.
C. For purposes of this Section, "health coverage plan" means any hospital, health, or medical expense insurance policy, hospital or medical service contract, employee welfare benefit plan, contract, or other agreement with a health maintenance organization or a preferred provider organization, health and accident insurance policy, or any other insurance contract of this type in this state, including a group insurance plan, a self-insurance plan, and the Office of Group Benefits programs. "Health coverage plan" shall not include a plan providing coverage for excepted benefits as defined in R.S. 22:1061, limited benefit health insurance plans, and short-term policies that have a term of less than twelve months.
Acts 2020, No. 222, §1, eff. Jan. 1, 2021; Acts 2022, No. 299, §1.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1055. Requirement for coverage of diagnosis and treatment for temporomandibular joint and associated musculature and neurology

RS 22:1055 - Requirement for coverage of diagnosis and treatment for temporomandibular joint and associated musculature and neurology
A. Every hospital, health, or medical expense insurance policy in the large group market as defined in R.S. 22:1091(B), delivered or issued for delivery in this state shall include coverage for diagnostic, therapeutic, or surgical procedures related to the temporomandibular joint (TMJ) and associated musculature and neurological conditions. This Section shall not apply to coverage provided by the Office of Group Benefits.
B. The coverage for diagnostic, therapeutic, or surgical procedures related to temporomandibular joint and associated musculature and neurological conditions shall be subject to the same conditions, limitations, precertification, prior authorization, referral procedures, copayment, and coinsurance provisions that apply to coverage for diagnostic, therapeutic, or surgical procedures involving other bones or joints of the human skeleton.
C. The provisions of this Section shall apply to all new policies, plans, certificates, and contracts issued on or after January 1, 2018. Existing policies, plans, certificates, and contracts shall include the coverage required by this Section on renewal thereof, but in no case later than January 1, 2019.
Acts 2016, No. 405, §1, eff. June 8, 2016.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1056. Health insurance coverage for incarcerated individuals

RS 22:1056 - Health insurance coverage for incarcerated individuals
A. Beginning January 1, 2019, every hospital, health, or medical expense insurance policy, hospital or medical service contract, employee welfare benefit plan, health and accident insurance policy, every policy of group, family group, blanket, or association health and accident insurance, and every self-insurance plan, health maintenance organization plan, and preferred provider organization plan, except for the Office of Group Benefits, delivered or issued for delivery in this state shall provide benefits for health care to the insured if he is detained in a correctional facility and has not been adjudicated or convicted of a criminal offense. Nothing herein shall alter any of the terms and conditions of the applicable coverage which shall remain applicable to all such services provided.
B. The provisions of this Section shall apply only if the detainee has valid health care coverage in effect at the time medical treatment is received and any premiums for such coverage are current.
C. The provisions of this Section shall apply to all existing hospital, health, or medical expense insurance policies, hospital or medical service contracts, employee welfare benefit plans, health and accident insurance policies, policies of group, family group, blanket, or association health and accident insurance, self-insurance plans, health maintenance organizations, and preferred provider organization policies, plans, and certificates in effect on January 1, 2019, and upon their renewal.
Acts 2018, No. 20, §1.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1057. Coverage for COVID-19 tests and treatments

RS 22:1057 - Coverage for COVID-19 tests and treatments
A. No health coverage plan delivered or issued for delivery in this state shall deny coverage for COVID-19 diagnostic tests, antibody tests, and antiviral drugs when ordered by a physician for the purpose of making clinical decisions or treating a patient suspected of having COVID-19.
B. Any health coverage plan delivered or issued for delivery in this state shall include coverage for COVID-19 diagnostic tests, antibody tests, and antiviral drugs in accordance with this Section.
C. The coverage required in this Section shall not be subject to annual deductibles, coinsurance, copayment, or any other out-of-pocket or cost-sharing expense provisions until December 31, 2021. After December 31, 2021, these services may be subject to these cost-sharing requirements.
D. For purposes of this Section, the following definitions apply:
(1) "COVID-19" means the coronavirus disease 2019 as designated by the World Health Organization.
(2)(a) "COVID-19 antibody test" means a test that meets all of the following requirements:
(i) Is fully approved or granted an Emergency Use Authorization by the United States Food and Drug Administration (FDA).
(ii) Follows the Enzyme-Linked Immunosorbent Assay (ELISA) test methodology performed in highly complex clinical laboratories and includes an antibody titer.
(iii) Is ordered by a physician for the purpose of determining the likelihood of a previous infection.
(b) "COVID-19 antibody test" shall not include a test used for employment-related or public health surveillance testing.
(3) "COVID-19 antiviral drug or agent" is a medication that is fully approved or granted an Emergency Use Authorization by the FDA for the treatment or prevention of COVID-19 infections when ordered by a physician.
(4) "COVID-19 diagnostic test" or "diagnosis test" means a test that is fully approved or granted an Emergency Use Authorization by the FDA and is ordered by a physician for the purpose of diagnosing an active infection or determining recovery from an active infection. "COVID-19 diagnostic test" or "diagnosis test" shall not include a test used for employment-related or public health surveillance testing.
(5) "Health coverage plan" means any hospital, health, or medical expense insurance policy, hospital or medical service contract, employee welfare benefit plan, contract, or other agreement with a health maintenance organization or a preferred provider organization, health and accident insurance policy, or any other insurance contract of this type in this state, including a group insurance plan, a self-insurance plan, and the Office of Group Benefits programs. "Health coverage plan" shall not include a plan providing coverage for excepted benefits as defined in R.S. 22:1061, limited benefit health insurance plans, high deductible health plans authorized under federal law, and short-term policies that have a term of less than twelve months.
Acts 2020, No. 230, §1, eff. June 11, 2020.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1058. Acupuncture; reimbursement

RS 22:1058 - Acupuncture; reimbursement
A.(1)(a) Any health coverage plan delivered or issued for delivery in this state in the large group market, as defined in R.S. 22:1091(B), shall provide coverage for any acupuncture performed by an individual licensed pursuant to R.S. 37:1356 et seq. when such services are medically necessary and not otherwise excluded from coverage.
(b) Terminology in a policy or contract deemed discriminatory against any person or method of practice, including but not limited to the manner of payment or reimbursement under the policy, shall be null and void.
(2) The coverage provided pursuant to this Section may be subject to annual deductibles, coinsurance, and copayment provisions as are consistent with those established under the health coverage plan.
(3) The coverage provided pursuant to this Section may be limited to twelve visits for acupuncture treatment per policy or contract benefit period.
B. For purposes of this Section, "health coverage plan" means any hospital, health, or medical expense insurance policy, hospital or medical service contract, employee welfare benefit plan, contract, or other agreement with a health maintenance organization or a preferred provider organization, health and accident insurance policy, or any other insurance contract of this type in this state, including a group insurance plan, a self-insurance plan, and the Office of Group Benefits programs. "Health coverage plan" shall not include a plan providing coverage for excepted benefits as defined in R.S. 22:1061, limited benefit health insurance plans, and short-term policies that have a term of less than twelve months.
Acts 2020, No. 250, §1, eff. Jan. 1, 2021.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1059.3. Required coverage for prescribed donor human milk

RS 22:1059.3 - Required coverage for prescribed donor human milk
A health coverage plan issued for delivery, delivered, renewed, or otherwise contracted for in this state shall provide inpatient and outpatient coverage benefits for up to two months for medically necessary pasteurized donor human milk upon prescription of an infant's pediatrician or licensed pediatric provider stating that the infant is medically or physically unable to receive maternal human milk or participate in breastfeeding, or the infant's mother is medically or physically unable to produce maternal human milk in sufficient quantities. A health coverage plan may limit coverage under this Section to inpatient and outpatient donor human milk obtained from a member bank of the Human Milk Banking Association of North America.
Acts 2023, No. 270, §1.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1060.2. Notice and disclosure of certain information required

RS 22:1060.2 - Notice and disclosure of certain information required
A health insurance issuer of a health benefit plan that covers prescription drugs and uses one or more drug formularies to specify the prescription drugs covered under the plan shall do all of the following:
(1) Provide in plain language in the coverage documentation provided to each enrollee each of the following:
(a) Notice that the plan uses one or more drug formularies.
(b) An explanation of what a drug formulary is.
(c) A statement regarding the method the health insurance issuer uses to determine the prescription drugs to be included in or excluded from a drug formulary.
(d) A statement of how often the health insurance issuer reviews the contents of each drug formulary.
(e) Notice, on a form approved by the Department of Insurance, that an enrollee may contact the health insurance issuer to determine whether a specific drug is included in a particular drug formulary.
(2) Disclose to an individual upon request, not later than the third business day after the date of the request, whether a specific drug is included in a particular drug formulary.
(3) Notify an enrollee and any other individual who requests information pursuant to this Section that the inclusion of a drug in a drug formulary does not guarantee that an enrollee's physician or other authorized prescriber will prescribe the drug for a particular medical condition or mental illness.
(4)(a) If a prescribed drug is denied based upon the drug's nonformulary status, provide the prescriber with a list of the alternative comparable formulary medications in writing and attached to the letter of denial of prescription drug coverage.
(b) If a prescribed drug is excluded from coverage under the health benefit plan and other drugs in the same class and used for the same treatment as the excluded drug are covered under the plan, the issuer or its agent shall notify the prescriber of the covered drug.
(c) It shall be deemed sufficient to meet the requirements of this Paragraph if a health benefit plan includes the information required by this Paragraph in the denial letter sent by the health benefit plan or its agent. For any request made by providers utilizing electronic health records with capabilities, the notice may be sent electronically.
(d) Simple notification of the availability and location of the formulary shall not be deemed sufficient to meet the requirements of this Paragraph.
Acts 2011, No. 350, §1, eff. Jan. 1, 2012; Acts 2019, No. 206, §1, eff. Jan. 1, 2020.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1060.3. Continuation of coverage required; other drugs not precluded

RS 22:1060.3 - Continuation of coverage required; other drugs not precluded
A. A health insurance issuer of a health benefit plan that covers prescription drugs shall offer to each enrollee at the contracted benefit level and until the enrollee's plan renewal date any prescription drug that was approved or covered under the plan for a medical condition or medical illness, regardless of whether the drug has been removed from the health benefit plan's drug formulary before the plan renewal date. Nothing herein shall prohibit the health insurance issuer from providing information to the enrollee regarding alternative covered drugs.
B. This Section shall not prohibit a physician or other authorized prescriber from prescribing a drug that is an alternative to a drug for which continuation of coverage is required by Subsection A of this Section if the alternative drug meets each of the following conditions:
(1) The drug is covered under the health benefit plan.
(2) The drug is medically appropriate for the enrollee.
C.(1) A health insurance issuer proposing to change its coverage of a particular prescription drug or intravenous infusion based on medical necessity shall give notice of the proposed change to an insured currently using that prescription drug or intravenous infusion who the health insurance issuer determines the change may affect if the health insurance issuer has covered the drug or intravenous infusion for the insured for at least the preceding sixty days. Such notice shall be sent at least sixty days prior to the effective date of the proposed change.
(2) Any insured receiving such a notice from a health insurance issuer shall have the right to appeal the proposed change during the sixty-day notification period provided for in Paragraph (1) of this Subsection in accordance with the Internal Claims and Appeals Process and External Review Act, R.S. 22:2391 et seq. 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.
Acts 2011, No. 350, §1, eff. Jan. 1, 2012; Acts 2012, No. 316, §1, eff. May 25, 2012; Acts 2016, No. 573, §1, eff. Jan. 1, 2017.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1060.4. Adverse determination

RS 22:1060.4 - Adverse determination
A. The refusal of a health insurance issuer to provide benefits to an enrollee for a prescription drug is an adverse determination for purposes of the Internal Claims and Appeals Process and External Review Act, R.S. 22:2391 et seq., if each of the following conditions is met:
(1) The drug is not included in a drug formulary used by the health benefit plan.
(2) The enrollee's physician or other authorized prescriber has determined the drug is medically necessary.
B. The enrollee may appeal the adverse determination pursuant to the Internal Claims and Appeals Process and External Review Act, R.S. 22:2391 et seq.
Acts 2011, No. 350, §1, eff. Jan. 1, 2012; Acts 2016, No. 573, §1, eff. Jan. 1, 2017.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1060.5. Specialty drug tiers; prohibitions; limits on copayments

RS 22:1060.5 - Specialty drug tiers; prohibitions; limits on copayments
A. A health insurance issuer of a health benefit plan that covers prescription drugs, as defined in R.S. 22:1060.1(8), and utilizes a formulary tier that is higher than a preferred or non-preferred brand drug tier, sometimes known as a specialty drug tier, shall limit any required copayment or coinsurance applicable to drugs on such tier to an amount not to exceed one hundred and fifty dollars per month for each drug up to a thirty-day supply of any single drug. This limit shall be inclusive of any copayment or coinsurance. This limit shall be applicable after any deductible is reached and until the individual's maximum out-of-pocket limit has been reached.
B. A health care issuer of a health benefit plan that covers prescription drugs, as defined in R.S. 22:1060.1(8), and utilizes specialty tiers shall be required to implement an exceptions process that allows enrollees to request an exception to the formulary. Under such an exception, a non-formulary specialty drug could be deemed covered under the formulary if the prescribing physician determines that the formulary drug for treatment of the same condition either would not be as effective for the individual, would have adverse effects for the individual, or both. In the event an enrollee is denied an exception, such denial shall be considered an adverse event and shall be subject to the health plan internal review process and the state external review process.
C. The provisions of this Section shall not apply to the Office of Group Benefits or to the claims of the Office of Group Benefits enrollees administered by health insurance issuers.
Acts 2014, No. 453, §1, eff. Jan. 1, 2015.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1060.6. Limitation; patient payment

RS 22:1060.6 - Limitation; patient payment
A. An individual shall not be required to make a payment for pharmacists' services in an amount greater than the pharmacist or pharmacy providing the pharmacists' services may retain from all payment sources.
B. No pharmacy benefit manager, insurer, or other entity that administers prescription drug benefits programs in this state shall prohibit by contract a pharmacy or pharmacist from informing a patient of all relevant options when acquiring his prescription medication, including but not limited to the cost and clinical efficacy of a more affordable alternative if one is available and the ability to pay cash if a cash price for the same drug is less than an insurance copayment or deductible payment amount.
C. Any provision of a contract that violates the provisions of this Section shall be unenforceable and shall be deemed an unfair or deceptive act and practice pursuant to R.S. 22:1961 et seq.
Acts 2016, No. 527, §1; Acts 2018, No. 597, §1, eff. Jan. 1, 2019.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1060.7. Prescription medication for chronic pain

RS 22:1060.7 - Prescription medication for chronic pain
A. Notwithstanding any provision of law to the contrary, when a licensed physician prescribes a nonopioid medication for the treatment of chronic pain, it shall be unlawful for a health insurance issuer to deny coverage of the nonopioid prescription drug in favor of an opioid prescription drug.
B. When an opioid prescription is deemed medically necessary and prescribed by a licensed physician, it shall be unlawful for an insurer to deny a prescribed medication and attempt to substitute an alternative medication that requires any of the following:
(1) An increased number of pills per prescription.
(2) A higher Drug Enforcement Administration schedule medication than the one prescribed.
(3) The substitution of an extended release medication that does not have defined abuse deterrent properties for a prescription of a medication that does have defined abuse deterrent properties.
Acts 2018, No. 372, §1; Acts 2018, No. 372, §1.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1060.12. Definitions

RS 22:1060.12 - Definitions
As used in this Subpart, the following definitions apply unless the context indicates otherwise:
(1) "Health coverage plan" means any hospital, health, or medical expense insurance policy, hospital or medical service contract, employee welfare benefit plan, contract, or other agreement with a health maintenance organization or a preferred provider organization, health and accident including a group insurance plan or self-insurance plan and the office of group benefits. "Health coverage plan" does not include a plan providing coverage for excepted benefits defined in R.S. 22:1061, limited benefit health insurance plans, and short-term policies that have a term of less than twelve months.
(2) "Health insurance issuer" means an entity subject to the Louisiana Insurance Code and applicable regulations, or subject to the jurisdiction of the commissioner, that contracts or offers to contract, or enters into an agreement to provide, deliver, arrange for, pay for, or reimburse any of the costs of healthcare services, including a sickness and accident insurance company, a health maintenance organization, a preferred provider organization or any similar entity, or any other entity providing a plan of health insurance or health benefits.
(3) "Nationally recognized clinical practice guidelines" means evidence-based clinical guidelines developed by independent organizations or medical professional societies, including but not limited to the National Comprehensive Cancer Network, the American Society of Clinical Oncology, and the American Society of Hematology, utilizing a transparent methodology and reporting structure and having policies against conflicts of interest. The guidelines shall establish best practices informed by a systematic review of evidence, an assessment of the benefits and costs of alternative care options, and recommendations intended to optimize patient care.
(4) "Positron emission tomography" means an imaging test that uses radioactive substances to visualize and measure metabolic processes in the body to help reveal how tissue and organs are functioning. The provisions of this Section shall not apply to non-melanomatous skin cancer.
(5) "Prior authorization" means a determination by a health insurance issuer or person contracting with a health insurance issuer that healthcare services ordered by the provider to an individual or an enrollee are medically necessary and appropriate.
(6) "Utilization review" means a set of formal techniques designed to monitor the use of, or evaluate the clinical necessity, appropriateness, efficacy, or efficiency of, healthcare services, procedures, or settings. Techniques include but are not limited to ambulatory review, prior authorization, second opinion, certification, concurrent review, case management, discharge planning, or retrospective review. "Utilization review" does not include elective requests for clarification of coverage.
Acts 2023, No. 254, §1.
2023 Louisiana Laws › Revised Statutes › Title 22 - Insurance › §22:1060.13. Prior authorization; time periods

RS 22:1060.13 - Prior authorization; time periods
A. For any services typically covered under the plan and related to the diagnosis or treatment of cancer for which prior authorization is required under a health coverage plan, the health insurance issuer shall offer an expedited review to the provider requesting prior authorization. The health insurance issuer shall communicate its decision on the prior authorization request to the provider as soon as possible, but in all cases no later than two business days from the receipt of the request for expedited review. If additional information is needed and requested for the issuer to make its determination, the issuer shall communicate its decision to the provider as soon as possible, but no later than forty-eight hours from receipt of the additional information.
B. For any services typically covered under the plan and related to the diagnosis or treatment of cancer for which prior authorization is required under a health coverage plan and for which the health insurance issuer does not receive a request for expedited review from the provider, the issuer shall communicate its decision on the prior authorization request no later than five days from the receipt of the request. If additional information is needed and requested for the issuer to make its determination, the issuer shall communicate its decision to the provider no more than two business days from receipt of the additional information.
C. The provisions of this Section shall apply only when the requesting provider clearly indicated that the request is related to the diagnosis or treatment of cancer.
D. The provisions of this Section shall not apply to non-melanomatous skin cancer.
Acts 2023, No. 254, §1.