AI-assisted research summary: Health insurers covered by this section must pay for medically necessary severe-obesity treatment, with some coverage limits and conditions.
§1047. Required coverage for severe obesity treatment A. A health insurance issuer offering health coverage plans in this state that provides hospital, medical, or surgical benefits for individuals covered under a respective plan shall provide coverage for medically necessary expenses for diseases and conditions caused by severe obesity and treatment in accordance with this Section. B.(1) Subsections C, D, E, and F of this Section shall apply only to a health insurance issuer offering health coverage plans in this state to the extent that services are covered by the Essential Health Benefits Benchmark Plan selected by the state in accordance with applicable federal regulations. (2) The Louisiana Department of Health shall evaluate bariatric surgery, pre-operative psychological screening and counseling, behavior modification, nutritional counseling, and post-operative follow-up, overview, and counseling of dietary, exercise, and lifestyle changes for coverage by the Essential Health Benefits Benchmark Plan during its next review of the Essential Health Benefits Benchmark Plan. C. Treatment shall include but not be limited to bariatric surgery, recognized by the American Society for Metabolic and Bariatric Surgery. Treatment shall also include pre-operative psychological screening and counseling, behavior modification, nutritional counseling, and post-operative follow-up, overview, and counseling of dietary, exercise, and lifestyle changes. D. The insured shall be at least eighteen years of age to be eligible for bariatric surgery coverage. Prior to the treatment required to be covered by this Section, a health insurance issuer may require a covered person to successfully complete a pre-operative period which may include counseling, nutritional education, and other covered services to assist in preparation and evaluation for successful treatment. E.(1) The prescribing physician shall issue a written order stating that treatment is medically necessary and in accordance with the patient qualifications and treatment standards set forth by the American Society for Metabolic and Bariatric Surgery or the American College of Surgeons. (2) A health insurance issuer may restrict covered services pursuant to this Section to those provided in facilities holding accreditation by the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery's Metabolic and Bariatric Surgery Accreditation. F.(1) A health insurance issuer may require that all covered services pursuant to this Section receive prior authorization from the issuer. (2) Nothing in this Section shall be interpreted to require a health insurance issuer to provide coverage for injectable drugs used to lower glucose levels or any other drugs prescribed for weight loss. A health insurance issuer may limit benefits provided in this Section to no more than one surgical procedure per lifetime. G. For purposes of this Section, the following terms have the following meanings: (1) "Body mass index" means a practical marker used to assess the degree of obesity, calculated by dividing the weight in kilograms by the height in meters squared. (2) "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, and a self-insurance plan. "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 or the Office of Group Benefits programs. (3) "Severe obesity" means either of the following: (a) A body mass index equal to or greater than forty kilograms per meter squared. (b) A body mass index equal to or greater than thirty-five kilograms per meter squared along with an associated comorbidity including but not limited to hypertension, cardiopulmonary conditions, sleep apnea, or diabetes. Acts 2024, No. 504, §1.