Provides for health insurance. (8/1/26)

Senate Bill 363 enacts a new provision in the Louisiana Insurance Code establishing requirements for health insurance coverage decisions. The legislation creates R.S. 22:1128.1, which prohibits health insurance issuers from substituting a lower level of care for otherwise covered medically necessary treatment when such substitution contradicts the treating provider's determination and is based primarily on cost-containment or utilization management criteria that conflict with generally accepted standards of care. The statute defines "lower level of care" as any healthcare service or setting providing less intensive treatment, monitoring, supervision, or therapeutic intervention than recommended by the treating provider. A critical exception preserves the insurer's ability to substitute a lower level of care if that alternative is consistent with generally accepted standards of medical practice and is clinically appropriate for the patient's condition.

Health insurance issuers operating in Louisiana are directly affected by this prohibition, as they must modify utilization review and care management practices to comply with the treating provider standard. Insured individuals benefit from protection against cost-driven downgrades of their care recommendations, though the exception for clinically appropriate alternatives under accepted medical standards preserves some insurer flexibility. Healthcare providers gain authority in treatment decisions, as insurers cannot override their care recommendations based solely on economic considerations that diverge from accepted medical practice standards. The practical impact centers on contested situations where an insurer's utilization management processes would reduce the intensity of recommended care, requiring that such reductions now align with both accepted medical practice standards and clinical appropriateness determinations.

The statute operates within Louisiana's existing health insurance regulatory framework under Title 22 of the Louisiana Revised Statutes. The legislation interacts with longstanding insurance law provisions governing coverage requirements and managed care practices, establishing new substantive limitations on cost-containment methodologies. The statute's reliance on "generally accepted standards of care" as a regulatory benchmark connects to existing medical practice standards embedded throughout Louisiana health law and reflects considerations of medical necessity commonly litigated in insurance coverage disputes. The effective date of August 1, 2026, provides prospective application to all health insurance issuers issuing or delivering policies in Louisiana.