Senate Bill 2791

AN ACT TO REQUIRE HEALTH INSURANCE COVERAGE OF MEDICALLY NECESSARY BARIATRIC SURGERY FOR TREATMENT OF CLINICALLY SEVERE OBESITY; AND FOR RELATED PURPOSES.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MISSISSIPPI:

SECTION 1. (1) For purposes of this act:

(a) "Bariatric surgery" means Roux-en-Y gastric bypass or biliopancreatic diversion, as defined by the National Institute of Health, or other gastrointestinal surgery identified by the National Institute of Health as effective for the treatment of clinically severe obesity, which may include gastric banding procedures if they are currently considered effective by the National Institute of Health and are indicated by an insured's specific medical condition.

(b) "Clinically severe obesity" means either a body mass index more than forty (40) kilograms per meter squared, or a body mass index between thirty-five (35) and forty (40) kilograms per meter squared combined with a serious comorbid condition including, but not limited to, diabetes or cardiopulmonary conditions such as hypertension, severe sleep apnea or heart disease. As used herein, body mass index equals weight in kilograms divided by height per meter squared.

(c) When a physician deems the patient's surgery "medically necessary" all indications above must be met in addition to the consideration of long term costs of the patient's condition without surgery.

(2) Notwithstanding any other provision of law to the contrary, any individual, franchise, blanket or group health insurance policy, medical service plan contract, hospital service corporation contract, hospital and medical service corporation contract, fraternal benefit society, health maintenance organization, preferred provider organization, or managed care organization which provides hospital, surgical, or medical expense insurance based on a physician's recommendation of "medical necessity" shall consider offering and make available coverage under any such policy, contract or plan for "medically necessary" bariatric surgery for the treatment of clinically severe obesity.

(3) The provisions of this section are applicable to all health benefit policies, programs or contracts which are offered by commercial insurance companies, nonprofit insurance companies, health maintenance organizations, preferred provider organizations and managed care organizations and which are entered into, delivered, issued for delivery, amended, or renewed after January 1, 2006.

(4) Reimbursement for the "medically necessary" treatment of clinically severe obesity by bariatric surgery shall be determined according to the same formula by which charges are developed for other medical and surgical procedures. Such coverage shall have durational limits, dollar limits, deductibles, copayments and coinsurance factors that are no less favorable than for other types of major surgery for treatment of physical illness or disease generally. Standards and criteria, including those related to diet, used by insurers to approve or restrict access to bariatric surgery for clinically severe obesity shall be based upon current clinical guidelines recognized by the National Institute of Health. Those standards may include the requirement that an insured document that physician-supervised weight control treatment has been ineffective in reducing the insured's weight below the levels articulated for clinically severe obesity, whether or not the policy, contract or plan provides coverage for physician-supervised weight control treatment. The surgeons contracted by the insurers to provide bariatric surgery for clinically severe obesity shall have current experience in bariatric surgery and shall meet the standards set forth by the National Institute of Health, if any.

(5) Nothing in this section shall be construed to prohibit any insurer from providing medical benefits greater than or more favorable to the insured than the benefits established pursuant to this section.

(6) The provisions of this section shall not apply to short term travel policies, short term nonrenewable policies of not more than six (6) months' duration, accident only policies, limited or specific disease policies, contracts designed for issuance to persons eligible for coverage under Title XVIII of the Social Security Act, known as Medicare or any other similar coverage under state or governmental plans.

SECTION 2. This act shall take effect and be in force from and after July 1, 2005.