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On May 28, 2014, Louisiana Senate Bill SB57 was sent to Governor Jindal for his signature. The bill, sponsored by Senator Sharon Weston Broome, adds a new section 1025.1 to Title 22 of the Louisiana Revised Statutes (R.S. 22:) that mandates inclusion of lymphedema treatment as an option in health insurance coverage effective with policies written after August 1, 2014. This bill, if signed into law, would "include as an option, ... covered benefits for the treatment of lymphedema ... including multilayer compression bandaging systems and custom or standard-fit gradient compression garments." The law would also mandate that insurers convert policies existing on August 1, 2014 to conform to the provisions of this new regulation on or before the renewal dates.

Why is this not an event to celebrate? To begin with, this is not a treatment mandate, but is a mandate to create an extra-cost insurance option to receive benefits that may already be included in current policies. Consider this: In 2002, prior to the passage of the Virginia lymphedema treatment mandate, the Virginia (VA) State Corporation Commission's Bureau of Insurance surveyed the top sixty writers of accident and sickness insurance in Virginia. Thirty-six companies then writing applicable business in Virginia responded. Of the 36, twenty-six companies (72%) claimed to already provide the lymphedema coverage required by VA House Bill 383. A similar survey was made in 2010 in connection with MA Senate Bill 896 and resulted in the determination "The bill requires insurers to pay for physical therapy, supplies, and equipment to treat lymphedema. Most insurers already cover basic medical treatment for lymphedema, and most currently cover therapy and supplies/equipment."

As I understand it there is no exclusion for lymphedema treatment in Louisiana policies, so no new law is needed to "cover benefits for the treatment of lymphedema". But the mandate to conform to the provisions of the new legislation allows insurers to cover lymphedema treatment only as an extra-cost option. More appropriate wording might have been: "As an alternative to offering optional coverage, including these benefits as standard benefits in such policies and programs shall be sufficient to comply with the requirements of this Subsection" [R.S. 22:1042] or "This Subsection does not prohibit a health benefit plan from providing coverage that is greater or more favorable to an insured than the requirements of this Subsection." [R.S. 22:1049.G(2)]. Either of these statements would have enabled patients to retain their current coverage of lymphedema treatment.

This bill mandates that policies cover "treatment of lymphedema", but does not define this treatment, nor the qualifications of the providers of this service. It has been 16 years since enactment of the Women's Health and Cancer Rights Act of 1998, and insurers still do not agree how to cover the required treatment of breast reconstruction-related lymphedema, i.e. manual lymph drainage by specially-qualified therapists, compression bandaging and compression garments, decongestion exercises and skin care, and the financial benefits of providing this treatment.

The placement of this new mandated option, §1025.1 is interesting. It is placed as a subsection of §1025. Treatment for alcoholism and drug abuse instead of as a separate mandate following the last mandate, §1053. Neither of these mandates (alcoholism and drug abuse §1025. or lymphedema §1025.1) has been included as an "essential benefit" for Louisiana insurance policies under the Affordable Care Act since they are "options" and not "state mandates".

The purpose of insurance is to spread risks over the entire insured population, and not cause an individual to gamble on what conditions he or she will need to be covered. We can use the cost data from Virginia, which has had a lymphedema treatment mandate for 9 years, to postulate the impact of lymphedema coverage in Louisiana under this new law. The claim experience in Virginia for an individual policy averaged $1.56/year/contract. Insurer-calculated premium impact was 0.45% of the $3,000 average annual individual policy cost, or $13.50/year/contract. (This ratio of incremental policy-to-claim cost of 8.65 lies within the 7-10 ratio observed by other investigators.)

If, instead of spreading the cost of lymphedema treatment across all insureds through a true mandate, we apply a population prevalence estimate of 1:1,000 and assume that only those at risk will pay for the lymphedema treatment policy option, the annual lymphedema premium increment becomes anywhere from $1,560 to $13,500 instead of $1.56 to $13.50. The cost to the lymphedema patient of a lymphedema treatment optional coverage policy could easily exceed the out-of-pocket cost of treatment.

Finally, I find the wording of the covered services somewhat ambiguous. Is a "multilayer compression bandaging system" a bandaging system utilizing multilayer bandages, or is it a bandaging system utilizing multiple layers of compression bandages, finger/toe bandages, tubular sleeves and padding? According to CMS the former does not require skilled bandagers while the latter does. And are "gradient compression garments" limited to stockings and sleeves, as the nomenclature is used in Medicare, or does it include compression vests, bras, abdominal/truncal bandages, facial and head masks, compression wraps and strapped adjustable garments?

In light of these issues, I fear that this Louisiana lymphedema mandate may not in fact be in the best interests of lymphedema patients. The law allows segregating lymphedema treatment from other medical treatment. It forces lymphedema patients to either forgo treatment they may have been receiving before the mandate, or to pay for an insurance policy option to continue to receive ill-defined coverage, since ambiguities in the definition of covered compression items leave interpretation to insurers who have demonstrated a colossal ignorance of the role of compression therapy in lymphedema treatment.

What remains to be done to redeem what could be a regressive situation for lymphedema patients, is for the lymphedema community to rally to ensure that Louisiana insurers clarify the good intention of this bill by writing insurance policies with the lymphedema patients' needs and resources in mind. Also required is creation of medical policies that reflect the medical needs of the lymphedema patient and that cover the spectrum of materials used in the treatment of lymphedema of all body sites and from all causes. Insurers must finally learn that "Lymphedema Treatment is Good Business as well as Good Medicine"©

The following is the official text of Louisiana Senate Bill No. 57.

Regular Session, 2014


To enact R.S. 22:1025.1, relative to health insurance; to mandate inclusion of coverage for the treatment of lymphedema as an option in certain policies; and to provide for related matters.

Be it enacted by the Legislature of Louisiana:

Section 1. R.S. 22:1025.1 is hereby enacted to read as follows:

§1025.1. Health insurance policies; mandated offering for treatment of lymphedema

  1. Any health insurance policy issued or issued for delivery in this state shall include as an option to be exercised by the policyholder, as defined therein, covered benefits for the treatment of lymphedema, rendered or prescribed by a physician licensed in this state or received in any licensed hospital or in any other public or private facility authorized to provide lymphedema treatment, including multilayer compression bandaging systems and custom or standard-fit gradient compression garments.
  2. Any insurer who, on August 1, 2014, has health insurance policies in force in this state shall convert such existing policies to conform to the provisions of this Section on or before the renewal dates.
  3. The provisions of this Section shall not apply to limited benefit health insurance policies or contracts authorized to be issued in this state.