HEALTH/ACC INSURANCE: Provides for health insurance. (8/1/26)

2026 Regular Session Introduced by Regina Barrow

Insurers cannot override a treating provider’s medically necessary care with lower-cost substitutes, unless the alternative is clinically appropriate and standards-based.

Read by title and returned to the Calendar, subject to call.

Purpose

SB 363 seeks to protect insured individuals from being forced to accept a lower level of care that would be contrary to the treating provider’s determination. It establishes a standard that health insurance issuers cannot override medically necessary treatment decisions based primarily on cost-containment or utilization management criteria, except when the substitute care meets generally accepted standards of medical practice and is clinically appropriate.

Key Provisions

Prohibition on substituting lower levels of care: An insurer may not require an insured to accept a lower level of care if doing so conflicts with the treating provider’s determination of what is medically necessary.

Definition of “lower level of care”: The bill defines this term as any health care service or setting that provides less intensive treatment, monitoring, supervision, or therapeutic intervention than what the treating provider recommends.

Exception for clinically appropriate alternatives: The prohibition does not apply if the substitute level of care is consistent with generally accepted standards of medical practice and is clinically appropriate for the patient’s condition.

Effective date: August 1, 2026.

New statute: Adds a new provision to R.S. 22:1128.1 establishing these requirements.

Who/What Would Be Affected

Stakeholders: Health insurer issuers in Louisiana, insured individuals/consumers receiving health coverage, and treating providers (physicians, clinicians) who determine medically necessary levels of care.

Impact on decisions: Insurers would need to honor the level of care determined medically necessary by the treating provider unless a clinically appropriate, generally accepted alternative exists.

Procedural and Timeline Aspects

Enactment timing: Takes effect on August 1, 2026.

Legislative status: Passed with favorable report as of April 22, 2026 (SB 363). Co-sponsor: Senator Regina Barrow.

Jurisdiction and scope: Applies to health insurance coverage decisions within Louisiana, addressing coverage determinations and utilization-management practices.

Practical Implications

Could reduce denial or substitution of medically indicated, higher-intensity care in favor of cost-saving alternatives.

May require insurers to justify any denial or substitutions that conflict with a treating provider’s recommended care plan.

Encourages alignment with generally accepted medical standards when offering alternatives to the originally recommended care.

If you’d like, I can tailor this summary for a specific audience (advocacy groups, insurers, or policymakers) or add a brief comparison to similar protections in other states.

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