RS 22:1128

§1128. Comprehensive health coverage A. Notwithstanding any other provision of law to the contrary, a health insurance policy or contract issued or issued for delivery in this state thirty days or more after rules promulgated pursuant to Subsection G of this Section become effective shall, at a minimum, provide coverage that incorporates an essential health benefits package consistent with the requirements of this Section. B. As used in this Section, "essential health benefits package" means coverage that: (1) Provides for the essential health benefits defined by the commissioner pursuant to Subsection C of this Section. (2) Limits cost sharing for coverage in accordance with Subsection E of this Section. (3) Provides for levels of coverage in accordance with Subsection F of this Section. C. The commissioner shall ensure that the scope of the essential health benefits package required pursuant to this Section is substantially similar to that of the essential health benefits required for a health plan subject to the federal Patient Protection and Affordable Care Act as of January 1, 2019. The commissioner shall define the essential health benefits required for a health plan, provided the definition includes at a minimum the following general categories and the items and services covered within the categories: (1) Ambulatory patient services. (2) Emergency services. (3) Hospitalization. (4) Maternity and newborn care. (5) Mental health and substance use disorder services, including behavioral health treatment. (6) Prescription drugs. (7) Rehabilitative and habilitative services and devices. (8) Laboratory services. (9) Preventive and wellness services and chronic disease management. (10) Pediatric services, including oral and vision care. D. In defining essential health benefits for purposes of this Section, the commissioner shall do the following: (1) Ensure that the essential health benefits reflect an appropriate balance among the categories enumerated in Subsection C of this Section, so that benefits are not unduly weighted toward any category. (2) Ensure that coverage decisions, determination of reimbursement rates, establishment of incentive programs, and designation of benefits are effected in ways that do not discriminate against individuals because of age, disability, or life expectancy. (3) Take into account the healthcare needs of diverse segments of the population, including women, children, persons with disabilities, and other groups. (4) Ensure that health benefits established as essential are not subject to denial to an individual, against the individual's wishes, on the basis of the individual's age or life expectancy or of the individual's present or predicted disability, degree of medical dependency, or quality of life. (5) Provide that a qualified health plan shall not be treated as providing coverage for the essential health benefits package described in Subsection B of this Section unless the plan complies with the provisions of the Patient Protection and Affordable Care Act, P. L. 111-148, relative to coverage and payment for emergency department services. (6) Provide that if a plan is offered through an exchange, another health plan offered through that exchange shall not fail to be treated as a qualified health plan solely because the plan does not offer coverage of benefits offered through the stand-alone plan that are otherwise required under Paragraph (C)(10) of this Section. (7) Annually review the essential health benefits package under Subsection B of this Section and submit a report to the legislature that contains the following: (a) An assessment of whether enrollees are facing any difficulty accessing needed services for reasons of coverage or cost. (b) An assessment of whether the essential health benefits package needs to be modified or updated to account for changes in medical evidence or scientific advancement. (c) Information on how the essential health benefits package will be modified to address any gaps in access or changes in the evidence base. (d) An assessment of the potential of additional or expanded benefits to increase costs and the interactions between the addition or expansion of benefits and reductions in existing benefits to meet actuarial limitations. (8) Periodically update the essential health benefits package under Subsection B of this Section to address any gaps in access to coverage or changes in the evidence base the commissioner identifies in the review conducted under Paragraph (7) of this Subsection. E. The commissioner shall establish annual limitations on cost sharing and deductibles that are substantially similar to the limitations for health plans subject to the federal Patient Protection and Affordable Care Act as of January 1, 2019. The commissioner may increase the annual limitation as needed to reflect any premium adjustment percentage. For purposes of this Subsection, "premium adjustment percentage" means the percentage, if any, by which the average per capita premium for health insurance coverage in the United States for the preceding calendar year, as estimated by the commissioner no later than October first of the preceding calendar year, exceeds the average per capita premium for 2019. F. The commissioner shall define levels of coverage that are substantially similar to the levels of coverage required for health plans subject to the federal Patient Protection and Affordable Care Act as of January 1, 2019. G. The commissioner shall promulgate rules pursuant to the Administrative Procedure Act to define "essential health benefits" pursuant to Subsection C of this Section, to establish annual limitations on cost sharing and deductibles pursuant to Subsection E of this Section, and to define required levels of coverage pursuant to Subsection F of this Section. H. Within thirty days of the effective date of rules promulgated that define essential health benefits as required pursuant to Subsection G of this Section or within thirty days after promulgating rules adopting any changes to the definition of essential health benefits, the commissioner shall submit a report summarizing the definition of essential health benefits to the House and Senate committees on insurance. I. This Section shall not be construed to prohibit a health plan from providing benefits in excess of the essential health benefits described in this Section. Acts 2019, No. 412, §1, eff. June 11, 2019.