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ENROLLED
ACT No. 8842026 Regular Session
HOUSE BILL NO. 1199
BY REPRESENTATIVES JORDAN, CHASSION, AND LACOMBE AND SENATORS
CARTER, EDMONDS, TALBOT, AND WHEAT
1 AN ACT
2 To enact R.S. 22:1049.1, relative to health insurance; to require coverage for genetic testing
3 for SCN2A associated disorders; to require coverage for medically necessary
4 treatment of SCN2A associated medical conditions; to provide for definitions; to
5 provide for medical necessity determinations; to provide for coverage standards; to
6 provide for prior authorization and cost-sharing requirements; to provide for
7 effectiveness; and to provide for related matters.
8 Be it enacted by the Legislature of Louisiana:
9 Section 1. R.S. 22:1049.1 is hereby enacted to read as follows:
10 §1049.1. Requirements for coverage for genetic testing and treatment of
11 SCN2A-associated medical conditions
12 A. For the purpose of this Section, the following terms have the meanings
13 ascribed to them:
14 (1) "Genetic testing" means a laboratory method used to detect changes in
15 genes, gene expression, or chromosomes in a person's cells or tissues. Genetic
16 testing may be done to look for inherited changes in a person's genes that may be a
17 sign that the person has an increased risk of developing a specific disease or
18 condition or of having a child or other family member that is covered under the
19 enrollee's policy with the disease or condition.
20 (2) "Health coverage plan" means any hospital, health, or medical expense
21 insurance policy, hospital or medical service contract, employee welfare benefit plan,
22 contract or agreement with a health maintenance organization or a preferred provider
23 organization, health and accident insurance policy, or any other insurance contract
24 of this type, including a group insurance plan and the Office of Group Benefits
25 programs.
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1 (3) "Medically necessary treatment" means health services necessary for the
2 diagnosis, treatment, cure, or alleviation of health conditions, illnesses, injuries, or
3 diseases. These services must be necessary and appropriate to address the specific
4 health issue or its associated symptoms, and must adhere to the generally accepted
5 standards of medical care within the community.
6 (4) "SCN2A" refers to a gene located on chromosome 2, which provides
7 critical instructions for the synthesis of a sodium channel protein essential for
8 neurotransmission in the brain. The SCN2A gene encodes a voltage-gated sodium
9 channel that plays a pivotal role in the generation of neuronal action potentials.
10 Pathogenic variants of the SCN2A gene are associated with a wide spectrum of
11 neurodevelopmental disorders, which may include but are not limited to neonatal or
12 infantile onset epilepsy, developmental delay, autism spectrum disorder, intellectual
13 disability, and movement disorders.
14 B. Any health coverage plan delivered, issued for delivery, renewed, or
15 otherwise contracted for in this state on or after January 1, 2027, shall provide
16 coverage for genetic testing to diagnose SCN2A-associated medical conditions when
17 ordered by a treating physician or advanced practice provider and determined to be
18 medically necessary by the health coverage plan.
19 C. A health coverage plan shall provide coverage for medically necessary
20 treatment of SCN2A-associated medical conditions, including but not limited to:
21 (1) Anti-seizure medications and other pharmacologic therapies.
22 (2) Rehabilitative and habilitative services, including physical, occupational,
23 speech, and behavioral therapies.
24 (3) Medically necessary durable medical equipment, assistive technology,
25 and adaptive devices.
26 (4) Nutritional, feeding, and gastrointestinal management services.
27 (5) Any additional treatment determined to be medically necessary by the
28 treating physician or advanced practice provider.
29 D. Medical necessity shall be determined by the enrollee's treating physician
30 or advanced practice provider. Any denial of coverage based on medical necessity
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1 shall be in writing and shall include the reasons for denial and an explanation of how
2 the request does not meet medical necessity standards. Denials may be appealed
3 pursuant to R.S. 22:1121 et seq.
4 E. A health coverage plan may require prior authorization for services
5 covered under this Section if such procedures are applied in a nondiscriminatory
6 manner and are no more restrictive than those applied to other benefits.
7 F. A health coverage plan may impose copayments, deductibles, or
8 coinsurance amounts on benefits required by this Section. Such cost-sharing shall
9 not be greater than that applied to other medical or surgical benefits under the plan.
10 G. A health coverage plan shall not deny coverage for genetic testing or
11 medically necessary treatment under this Section on the basis of disability,
12 developmental status, or preexisting condition.
13 H. Benefits required by this Section shall be considered rehabilitative or
14 habilitative services and devices for purposes of any state or federal requirement for
15 coverage of essential health benefits.
16 I. The provisions of this Section do not apply to limited benefit health
17 insurance policies or contracts.
18 Section 2. This Act shall become effective upon signature by the governor or, if not
19 signed by the governor, upon expiration of the time for bills to become law without signature
20 by the governor, as provided by Article III, Section 18 of the Constitution of Louisiana. If
21 vetoed by the governor and subsequently approved by the legislature, this Act shall become
22 effective on the day following such approval.
SPEAKER OF THE HOUSE OF REPRESENTATIVES
PRESIDENT OF THE SENATE
GOVERNOR OF THE STATE OF LOUISIANA
APPROVED:
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