Connecticut 2016 Regular Session

Connecticut Senate Bill SB00034 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
1		-	General Assembly ~~Corrected Copy~~ Raised Bill No. 34
	1	+	General Assembly Raised Bill No. 34
2	2		February Session, 2016 LCO No. 462
3		-	_____~~SB00034INS~~__~~_030416____~~
	3	+	00462_______INS
4	4		Referred to Committee on INSURANCE AND REAL ESTATE
5	5		Introduced by:
6	6		(INS)
7	7
8	8		General Assembly
9		-
10		-	Corrected Copy
11	9
12	10		Raised Bill No. 34
13	11
14	12		February Session, 2016
15	13
16	14		LCO No. 462
17	15
18		-	_____~~SB00034INS~~__~~_030416____~~
	16	+	00462_______INS
19	17
20	18		Referred to Committee on INSURANCE AND REAL ESTATE
21	19
22	20		Introduced by:
23	21
24	22		(INS)
25	23
26	24		AN ACT CONCERNING DISPENSATION AND COVERAGE OF A PRESCRIBED DRUG FOR A CHRONIC DISEASE DURING CERTAIN ADVERSE DETERMINATION REVIEWS, AND DECREASING THE TIME FRAMES FOR URGENT CARE ADVERSE DETERMINATION REVIEW REQUESTS.
27	25
28	26		Be it enacted by the Senate and House of Representatives in General Assembly convened:
29	27
30	28		Section 1. Subsection (b) of section 38a-591d of the 2016 supplement to the general statutes is repealed and the following is substituted in lieu thereof (Effective January 1, 2017):
31	29
32	30		(b) With respect to a nonurgent care request:
33	31
34	32		(1) (A) For a prospective or concurrent review request, a health carrier shall make a determination within a reasonable period of time appropriate to the covered person's medical condition, but not later than fifteen calendar days after the date the health carrier receives such request, and shall notify the covered person and, if applicable, the covered person's authorized representative of such determination, whether or not the carrier certifies the provision of the benefit.
35	33
36	34		(B) If the review under subparagraph (A) of this subdivision is a review of a grievance involving a concurrent review request, pursuant to 45 CFR 147.136, as amended from time to time, the treatment shall be continued without liability to the covered person until the covered person has been notified of the review decision.
37	35
38	36		(C) (i) If the review under subparagraph (A) of this subdivision is a review of a grievance involving a prospective review request relating to the dispensing of a drug for a chronic disease, other than a schedule II or III controlled substance, that is prescribed by a licensed participating provider who is a specialist in such chronic disease, the health carrier shall issue an electronic authorization to the covered person's pharmacy for the dispensing of a temporary supply of such drug sufficient for the duration of such review until the covered person has been notified of the review decision. Such authorization shall include confirmation of the availability of payment for such supply of such drug.
39	37
40	38		(ii) Not later than twenty-four hours after the health carrier has issued such authorization to the pharmacy and prior to the pharmacy's dispensation of such drug, such health carrier shall confirm with such participating provider the provider's concurrence with the dispensing of such temporary supply of such drug. If such participating provider does not concur, the health carrier shall cancel such authorization.
41	39
42	40		(iii) The provisions of this subparagraph shall not apply to a grievance or review of an adverse determination under this section concerning the substitution of a generic drug or another brand name drug for a prescribed brand name drug unless the prescribing licensed participating provider has specified that there shall be no substitution for the specified brand name drug.
43	41
44	42		(2) For a retrospective review request, a health carrier shall make a determination within a reasonable period of time, but not later than thirty calendar days after the date the health carrier receives such request.
45	43
46	44		(3) The time periods specified in subdivisions (1) and (2) of this subsection may be extended once by the health carrier for up to fifteen calendar days, provided the health carrier:
47	45
48	46		(A) Determines that an extension is necessary due to circumstances beyond the health carrier's control; and
49	47
50	48		(B) Notifies the covered person and, if applicable, the covered person's authorized representative prior to the expiration of the initial time period, of the circumstances requiring the extension of time and the date by which the health carrier expects to make a determination.
51	49
52	50		(4) (A) If the extension pursuant to subdivision (3) of this subsection is necessary due to the failure of the covered person or the covered person's authorized representative to provide information necessary to make a determination on the request, the health carrier shall:
53		-
54		-	(i) Specifically describe in the notice of extension the required information necessary to complete the request; and
55		-
56		-	(ii) Provide the covered person and, if applicable, the covered person's authorized representative with not less than forty-five calendar days after the date of receipt of the notice to provide the specified information.
57		-
58		-	(B) If the covered person or the covered person's authorized representative fails to submit the specified information before the end of the period of the extension, the health carrier may deny certification of the benefit requested.
59	51
60	52		Sec. 2. Subsection (c) of section 38a-591e of the general statutes is repealed and the following is substituted in lieu thereof (Effective January 1, 2017):
61	53
62	54		(c) (1) (A) When conducting a review of an adverse determination under this section, the health carrier shall ensure that such review is conducted in a manner to ensure the independence and impartiality of the clinical peer or peers involved in making the review decision.
63	55
64	56		(B) If the adverse determination involves utilization review, the health carrier shall designate an appropriate clinical peer or peers to review such adverse determination. Such clinical peer or peers shall not have been involved in the initial adverse determination.
65	57
66	58		(C) The clinical peer or peers conducting a review under this section shall take into consideration all comments, documents, records and other information relevant to the covered person's benefit request that is the subject of the adverse determination under review, that are submitted by the covered person or the covered person's authorized representative, regardless of whether such information was submitted or considered in making the initial adverse determination.
67	59
68	60		(D) Prior to issuing a decision, the health carrier shall provide free of charge, by facsimile, electronic means or any other expeditious method available, to the covered person or the covered person's authorized representative, as applicable, any new or additional documents, communications, information and evidence relied upon and any new or additional scientific or clinical rationale used by the health carrier in connection with the grievance. Such documents, communications, information, evidence and rationale shall be provided sufficiently in advance of the date the health carrier is required to issue a decision to permit the covered person or the covered person's authorized representative, as applicable, a reasonable opportunity to respond prior to such date.
69	61
70	62		(2) If the review under subdivision (1) of this subsection is an expedited review, all necessary information, including the health carrier's decision, shall be transmitted between the health carrier and the covered person or the covered person's authorized representative, as applicable, by telephone, facsimile, electronic means or any other expeditious method available.
71	63
72	64		(3) If the review under subdivision (1) of this subsection is an expedited review of a grievance involving an adverse determination of a concurrent review request, pursuant to 45 CFR 147.136, as amended from time to time, the treatment shall be continued without liability to the covered person until the covered person has been notified of the review decision.
73	65
74	66		(4) (A) If the review under subdivision (1) of this subsection is a review of a grievance involving a prospective review request relating to the dispensing of a drug for a chronic disease, other than a schedule II or III controlled substance, that is prescribed by a licensed participating provider who is a specialist in such chronic disease, the health carrier shall issue an electronic authorization to the covered person's pharmacy for the dispensing of a temporary supply of such drug sufficient for the duration of such review until the covered person has been notified of the review decision. Such authorization shall include confirmation of the availability of payment for such supply of such drug.
75	67
76	68		(B) Not later than twenty-four hours after the health carrier has issued such authorization to the pharmacy and prior to the pharmacy's dispensation of such drug, such health carrier shall confirm with such participating provider the provider's concurrence with the dispensing of such temporary supply of such drug. If such participating provider does not concur, the health carrier shall cancel such authorization.
77	69
78	70		(C) The provisions of this subdivision shall not apply to a grievance or review of an adverse determination under this section concerning the substitution of a generic drug or another brand name drug for a prescribed brand name drug unless the prescribing licensed participating provider has specified that there shall be no substitution for the specified brand name drug.
79	71
80	72		Sec. 3. Subdivision (1) of subsection (c) of section 38a-591d of the 2016 supplement to the general statutes is repealed and the following is substituted in lieu thereof (Effective January 1, 2017):
81	73
82	74		(1) (A) Unless the covered person or the covered person's authorized representative has failed to provide information necessary for the health carrier to make a determination and except as specified under subparagraph (B) of this subdivision, the health carrier shall make a determination as soon as possible, taking into account the covered person's medical condition, but not later than [seventy-two] forty-eight hours after the health carrier receives such request, provided, if the urgent care request is a concurrent review request to extend a course of treatment beyond the initial period of time or the number of treatments, such request is made at least twenty-four hours prior to the expiration of the prescribed period of time or number of treatments.
83	75
84	76		(B) Unless the covered person or the covered person's authorized representative has failed to provide information necessary for the health carrier to make a determination, for an urgent care request specified under subparagraph (B) or (C) of subdivision (38) of section 38a-591a, the health carrier shall make a determination as soon as possible, taking into account the covered person's medical condition, but not later than twenty-four hours after the health carrier receives such request, provided, if the urgent care request is a concurrent review request to extend a course of treatment beyond the initial period of time or the number of treatments, such request is made at least twenty-four hours prior to the expiration of the prescribed period of time or number of treatments.
85	77
86	78		Sec. 4. Subdivision (1) of subsection (d) of section 38a-591e of the general statutes is repealed and the following is substituted in lieu thereof (Effective January 1, 2017):
87	79
88	80		(d) (1) The health carrier shall notify the covered person and, if applicable, the covered person's authorized representative, in writing or by electronic means, of its decision within a reasonable period of time appropriate to the covered person's medical condition, but not later than:
89	81
90	82		(A) For prospective review and concurrent review requests, thirty calendar days after the health carrier receives the grievance;
91	83
92	84		(B) For retrospective review requests, sixty calendar days after the health carrier receives the grievance;
93	85
94	86		(C) For expedited review requests, except as specified under subparagraph (D) of this subdivision, [seventy-two] forty-eight hours after the health carrier receives the grievance; and
95	87
96	88		(D) For expedited review requests of a health care service or course of treatment specified under subparagraph (B) or (C) of subdivision (38) of section 38a-591a, twenty-four hours after the health carrier receives the grievance.
97	89
98	90		Sec. 5. Subdivision (1) of subsection (i) of section 38a-591g of the general statutes is repealed and the following is substituted in lieu thereof (Effective January 1, 2017):
99	91
100	92		(i) (1) The independent review organization shall notify the commissioner, the health carrier, the covered person and, if applicable, the covered person's authorized representative in writing of its decision to uphold, reverse or revise the adverse determination or the final adverse determination, not later than:
101	93
102	94		(A) For external reviews, forty-five calendar days after such organization receives the assignment from the commissioner to conduct such review;
103	95
104	96		(B) For external reviews involving a determination that the recommended or requested health care service or treatment is experimental or investigational, twenty calendar days after such organization receives the assignment from the commissioner to conduct such review;
105	97
106	98		(C) For expedited external reviews, except as specified under subparagraph (D) of this subdivision, as expeditiously as the covered person's medical condition requires, but not later than [seventy-two] forty-eight hours after such organization receives the assignment from the commissioner to conduct such review;
107	99
108	100		(D) For expedited external reviews involving a health care service or course of treatment specified under subparagraph (B) or (C) of subdivision (38) of section 38a-591a, as expeditiously as the covered person's medical condition requires, but not later than twenty-four hours after such organization receives the assignment from the commissioner to conduct such review; and
109	101
110	102		(E) For expedited external reviews involving a determination that the recommended or requested health care service or treatment is experimental or investigational, as expeditiously as the covered person's medical condition requires, but not later than five calendar days after such organization receives the assignment from the commissioner to conduct such review.
111	103
112	104
113	105
114	106
115	107		This act shall take effect as follows and shall amend the following sections:
116	108		Section 1 January 1, 2017 38a-591d(b)
117	109		Sec. 2 January 1, 2017 38a-591e(c)
118	110		Sec. 3 January 1, 2017 38a-591d(c)(1)
119	111		Sec. 4 January 1, 2017 38a-591e(d)(1)
120	112		Sec. 5 January 1, 2017 38a-591g(i)(1)
121	113
122	114		This act shall take effect as follows and shall amend the following sections:
123	115
124	116		Section 1
125	117
126	118		January 1, 2017
127	119
128	120		38a-591d(b)
129	121
130	122		Sec. 2
131	123
132	124		January 1, 2017
133	125
134	126		38a-591e(c)
135	127
136	128		Sec. 3
137	129
138	130		January 1, 2017
139	131
140	132		38a-591d(c)(1)
141	133
142	134		Sec. 4
143	135
144	136		January 1, 2017
145	137
146	138		38a-591e(d)(1)
147	139
148	140		Sec. 5
149	141
150	142		January 1, 2017
151	143
152	144		38a-591g(i)(1)
153	145
	146	+	Statement of Purpose:
154	147
	148	+	To establish procedures for the dispensation of and coverage for a prescribed drug for a chronic disease during certain adverse determination reviews, and decrease the time frame for urgent care adverse determination review requests from seventy-two hours to forty-eight hours.
155	149
156		-	INS Joint Favorable
157		-
158		-	INS
159		-
160		-	Joint Favorable
	150	+	[Proposed deletions are enclosed in brackets. Proposed additions are indicated by underline, except that when the entire text of a bill or resolution or a section of a bill or resolution is new, it is not underlined.]