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General Assembly Committee Bill No. 6088
January Session, 2019
LCO No. 5487
Referred to Committee on INSURANCE AND REAL ESTATE
Introduced by:
(INS)
AN ACT CONCERNING CONTRACTING HEALTH O RGANIZATIONS
AND DENTISTS, DENTAL PLANS AND PROCEDURES .
Be it enacted by the Senate and House of Representatives in General
Assembly convened:
Section 1. Section 38a-479 of the general statutes is repealed and the 1
following is substituted in lieu thereof (Effective January 1, 2020): 2
(a) As used in this section and section 38a-479b: 3
(1) "Contracting health organization" means a managed care 4
organization, as defined in section 38a-478, or a preferred provider 5
network, as defined in section 38a-479aa. 6
(2) "Provider" means a physician, surgeon, chiropractor, podiatrist, 7
psychologist, optometrist, dentist, naturopath or advanced practice 8
registered nurse licensed in this state or a group or organization of 9
such individuals, who has entered into or renews a participating 10
provider contract with a contracting health organization to render 11
services to such organization's enrollees and enrollees' dependents. 12
(b) Each contracting health organization shall establish and 13
implement a procedure to provide to each provider: 14
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(1) Access via the Internet or other electronic or digital format to the 15
contracting health organization's fees for (A) the current procedural 16
terminology (CPT) codes or current dental terminology (CDT) codes 17
applicable to such provider's specialty, (B) the Health Care Procedure 18
Coding System (HCPCS) codes applicable to such provider, and (C) 19
such CPT codes, CDT codes and HCPCS codes as may be requested by 20
such provider for other services such provider actually bills or intends 21
to bill the contracting health organization, provided such codes are 22
within the provider's specialty or subspecialty; and 23
(2) Access via the Internet or other electronic or digital format to the 24
contracting health organization's policies and procedures regarding 25
(A) payments to providers, (B) providers' duties and requirements 26
under the participating provider contract, (C) inquiries and appeals 27
from providers, including contact information for the office or offices 28
responsible for responding to such inquiries or appeals and a 29
description of the rights of a provider, enrollee and enrollee's 30
dependents with respect to an appeal. 31
(c) The provisions of subdivision (1) of subsection (b) of this section 32
shall not apply to any provider whose services are reimbursed in a 33
manner that does not utilize current procedural terminology (CPT) or 34
current dental terminology (CDT) codes. 35
(d) The fee information received by a provider pursuant to 36
subdivision (1) of subsection (b) of this section is proprietary and shall 37
be confidential, and the procedure adopted pursuant to this section 38
may contain penalties for the unauthorized distribution of fee 39
information, which may include termination of the participating 40
provider contract. 41
Sec. 2. Subsection (a) of section 38a-479b of the general statutes is 42
repealed and the following is substituted in lieu thereof (Effective 43
January 1, 2020): 44
(a) No contracting health organization shall make material changes 45
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to a provider's fee schedule except as follows: 46
(1) At one time annually, provided providers are given at least 47
ninety days' advance notice by mail, electronic mail or facsimile by 48
such organization of any such changes. With respect to a dental plan, 49
such notice shall include the maximum allowable charge for each 50
dental procedure code. Upon receipt of such notice, a provider may 51
terminate the participating provider contract with at least sixty days' 52
advance written notice to the contracting health organization; 53
(2) At any time for the following, provided providers are given at 54
least thirty days' advance notice by mail, electronic mail or facsimile by 55
such organization of any such changes: 56
(A) To comply with requirements of federal or state law, regulation 57
or policy. If such federal or state law, regulation or policy takes effect 58
in less than thirty days, the organization shall give providers as much 59
notice as possible; 60
(B) To comply with changes to the medical data code sets set forth 61
in 45 CFR 162.1002, as amended from time to time; 62
(C) To comply with changes to national best practice protocols made 63
by the National Quality Forum or other national accrediting or 64
standard-setting organization based on peer-reviewed medical 65
literature generally recognized by the relevant medical community or 66
the results of clinical trials generally recognized and accepted by the 67
relevant medical community; 68
(D) To be consistent with changes made in Medicare pertaining to 69
billing or medical management practices, provided any such changes 70
are applied to relevant participating provider contracts where such 71
changes pertain to the same specialty or payment methodology; 72
(E) If a drug, treatment, procedure or device is identified as no 73
longer safe and effective by the federal Food and Drug Administration 74
or by peer-reviewed medical literature generally recognized by the 75
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relevant medical community; 76
(F) To address payment or reimbursement for a new drug, 77
treatment, procedure or device that becomes available and is 78
determined to be safe and effective by the federal Food and Drug 79
Administration or by peer-reviewed medical literature generally 80
recognized by the relevant medical community; or 81
(G) As mutually agreed to by the contracting health organization 82
and the provider. If the contracting health organization and the 83
provider do not mutually agree, the provider's current fee schedule 84
shall remain in force until the annual change permitted pursuant to 85
subdivision (1) of this subsection. 86
This act shall take effect as follows and shall amend the following
sections:
Section 1 January 1, 2020 38a-479
Sec. 2 January 1, 2020 38a-479b(a)
Statement of Purpose:
To subject dentists, dental plans and procedures to fee transparency
requirements that apply to contracts between other providers and
contracting health organizations.
[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.]
Co-Sponsors: REP. PETIT, 22nd Dist.
H.B. 6088