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General Assembly Committee Bill No. 37
January Session, 2019
LCO No. 5682
Referred to Committee on INSURANCE AND REAL ESTATE
Introduced by:
(INS)
AN ACT REQUIRING HEA LTH INSURANCE COVERAGE O F A
PRESCRIBED DRUG DURI NG ADVERSE DETERMINA TION REVIEWS
AND EXTERNAL REVIEW PROCESSES.
Be it enacted by the Senate and House of Representatives in General
Assembly convened:
Section 1. Subsection (b) of section 38a-591d of the general statutes is 1
repealed and the following is substituted in lieu thereof (Effective 2
January 1, 2020): 3
(b) With respect to a nonurgent care request: 4
(1) (A) For a prospective or concurrent review request, a health 5
carrier shall make a determination within a reasonable period of time 6
appropriate to the covered person's medical condition, but not later 7
than fifteen calendar days after the date the health carrier receives such 8
request, and shall notify the covered person and, if applicable, the 9
covered person's authorized representative of such determination, 10
whether or not the carrier certifies the provision of the benefit. 11
(B) If the review under subparagraph (A) of this subdivision is a 12
review of a grievance involving a concurrent review request, pursuant 13
to 45 CFR 147.136, as amended from time to time, the treatment shall 14
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be continued without liability to the covered person until the covered 15
person has been notified of the review decision. 16
(C) (i) Notwithstanding subparagraph (B) of this subdivision, if a 17
covered person or the covered person's authorized representative files 18
any grievance or requests any review of an adverse determination 19
pursuant to this section relating to the dispensation of a drug, other 20
than a schedule II or III controlled substance, prescribed by a licensed 21
participating provider, the health carrier shall issue immediate 22
electronic authorization to the covered person's pharmacy to dispense 23
a temporary supply of the drug sufficient for the duration of the 24
grievance or review. The authorization shall include confirmation of 25
the availability of payment for such supply of such drug. 26
(ii) Not later than twenty-four hours after the health carrier has 27
issued such authorization to the pharmacy and prior to the pharmacy's 28
dispensation of such drug, such health carrier shall confirm with the 29
licensed participating provider the provider's concurrence with the 30
dispensing of such temporary supply of such drug. If such licensed 31
participating provider does not concur, the health carrier shall cancel 32
such authorization. 33
(iii) The provisions of this subparagraph shall not apply to a 34
grievance or review of an adverse determination under this section 35
concerning the substitution of a generic drug or another brand name 36
drug for a prescribed brand name drug unless the prescribing licensed 37
participating provider has specified that there shall be no substitution 38
for the specified brand name drug. 39
(2) For a retrospective review request, a health carrier shall make a 40
determination within a reasonable period of time, but not later than 41
thirty calendar days after the date the health carrier receives such 42
request. 43
(3) The time periods specified in subdivisions (1) and (2) of this 44
subsection may be extended once by the health carrier for up to fifteen 45
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calendar days, provided the health carrier: 46
(A) Determines that an extension is necessary due to circumstances 47
beyond the health carrier's control; and 48
(B) Notifies the covered person and, if applicable, the covered 49
person's authorized representative prior to the expiration of the initial 50
time period, of the circumstances requiring the extension of time and 51
the date by which the health carrier expects to make a determination. 52
(4) (A) If the extension pursuant to subdivision (3) of this subsection 53
is necessary due to the failure of the covered person or the covered 54
person's authorized representative to provide information necessary to 55
make a determination on the request, the health carrier shall: 56
(i) Specifically describe in the notice of extension the required 57
information necessary to complete the request; and 58
(ii) Provide the covered person and, if applicable, the covered 59
person's authorized representative with not less than forty-five 60
calendar days after the date of receipt of the notice to provide the 61
specified information. 62
(B) If the covered person or the covered person's authorized 63
representative fails to submit the specified information before the end 64
of the period of the extension, the health carrier may deny certification 65
of the benefit requested. 66
Sec. 2. Subsection (c) of section 38a-591e of the general statutes is 67
repealed and the following is substituted in lieu thereof (Effective 68
January 1, 2020): 69
(c) (1) (A) When conducting a review of an adverse determination 70
under this section, the health carrier shall ensure that such review is 71
conducted in a manner to ensure the independence and impartiality of 72
the clinical peer or peers involved in making the review decision. 73
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(B) If the adverse determination involves utilization review, the 74
health carrier shall designate an appropriate clinical peer or peers to 75
review such adverse determination. Such clinical peer or peers shall 76
not have been involved in the initial adverse determination. 77
(C) The clinical peer or peers conducting a review under this section 78
shall take into consideration all comments, documents, records and 79
other information relevant to the covered person's benefit request that 80
is the subject of the adverse determination under review, that are 81
submitted by the covered person or the covered person's authorized 82
representative, regardless of whether such information was submitted 83
or considered in making the initial adverse determination. 84
(D) Prior to issuing a decision, the health carrier shall provide free 85
of charge, by facsimile, electronic means or any other expeditious 86
method available, to the covered person or the covered person's 87
authorized representative, as applicable, any new or additional 88
documents, communications, information and evidence relied upon 89
and any new or additional scientific or clinical rationale used by the 90
health carrier in connection with the grievance. Such documents, 91
communications, information, evidence and rationale shall be 92
provided sufficiently in advance of the date the health carrier is 93
required to issue a decision to permit the covered person or the 94
covered person's authorized representative, as applicable, a reasonable 95
opportunity to respond prior to such date. 96
(2) If the review under subdivision (1) of this subsection is an 97
expedited review, all necessary information, including the health 98
carrier's decision, shall be transmitted between the health carrier and 99
the covered person or the covered person's authorized representative, 100
as applicable, by telephone, facsimile, electronic means or any other 101
expeditious method available. 102
(3) If the review under subdivision (1) of this subsection is an 103
expedited review of a grievance involving an adverse determination of 104
a concurrent review request, pursuant to 45 CFR 147.136, as amended 105
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from time to time, the treatment shall be continued without liability to 106
the covered person until the covered person has been notified of the 107
review decision. 108
(4) (A) Notwithstanding subdivision (3) of this subsection, if a 109
covered person or the covered person's authorized representative files 110
any grievance or requests any review of an adverse determination 111
pursuant to this section relating to the dispensation of a drug, other 112
than a schedule II or III controlled substance, prescribed by a licensed 113
participating provider, the health carrier shall issue immediate 114
electronic authorization to the covered person's pharmacy to dispense 115
a temporary supply of the drug sufficient for the duration of the 116
grievance or review. The authorization shall include confirmation of 117
the availability of payment for such supply of such drug. 118
(B) Not later than twenty-four hours after the health carrier has 119
issued such authorization to the pharmacy and prior to the pharmacy's 120
dispensation of such drug, such health carrier shall confirm with the 121
licensed participating provider the provider's concurrence with the 122
dispensing of such temporary supply of such drug. If such licensed 123
participating provider does not concur, the health carrier shall cancel 124
such authorization. 125
(C) The provisions of this subdivision shall not apply to a grievance 126
or review of an adverse determination under this section concerning 127
the substitution of a generic drug or another brand name drug for a 128
prescribed brand name drug unless the prescribing licensed 129
participating provider has specified that there shall be no substitution 130
for the specified brand name drug. 131
Sec. 3. Subsection (b) of section 38a-591f of the general statutes is 132
repealed and the following is substituted in lieu thereof (Effective 133
January 1, 2020): 134
(b) (1) A covered person or the covered person's authorized 135
representative may file a grievance of an adverse determination that 136
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was not based on medical necessity with the health carrier not later 137
than one hundred eighty calendar days after the covered person or the 138
covered person's representative, as applicable, receives the notice of an 139
adverse determination. 140
(2) (A) If a covered person or the covered person's authorized 141
representative files any grievance or requests any review of an adverse 142
determination pursuant to this section relating to the dispensation of a 143
drug, other than a schedule II or III controlled substance, prescribed by 144
a licensed participating provider, the health carrier shall issue 145
immediate electronic authorization to the covered person's pharmacy 146
to prescribe a temporary supply of the drug sufficient for the duration 147
of the grievance or review. The a uthorization shall include 148
confirmation of the availability of payment for such supply of such 149
drug. 150
(B) Not later than twenty-four hours after the health carrier has 151
issued such authorization to the pharmacy and prior to the pharmacy's 152
dispensation of such drug, such health carrier shall confirm with the 153
licensed participating provider the provider's concurrence with the 154
dispensing of such temporary supply of such drug. If such licensed 155
participating provider does not concur, the health carrier shall cancel 156
such authorization. 157
(C) The provisions of this subdivision shall not apply to a grievance 158
or review of an adverse determination under this section concerning 159
the substitution of a generic drug or another brand name drug for a 160
prescribed brand name drug unless the prescribing licensed 161
participating provider has specified that there shall be no substitution 162
for the specified brand name drug. 163
[(2)] (3) The health carrier shall notify the covered person and, if 164
applicable, the covered person's authorized representative not later 165
than three business days after the health carrier receives a grievance 166
the covered person or the covered person's authorized representative, 167
as applicable, is entitled to submit written material to the health carrier 168
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to be considered when conducting a review of the grievance. 169
[(3)] (4) (A) Upon receipt of a grievance, a health carrier shall 170
designate an individual or individuals to conduct a review of the 171
grievance. 172
(B) The health carrier shall not designate the same individual or 173
individuals who denied the claim or handled the matter that is the 174
subject of the grievance to conduct the review of the grievance. 175
(C) The health carrier shall provide the covered person and, if 176
applicable, the covered person's authorized representative with the 177
name, address and telephone number of the individual or the 178
organizational unit designated to coordinate the review on behalf of 179
the health carrier. 180
Sec. 4. Subsection (b) of section 38a-591g of the general statutes is 181
repealed and the following is substituted in lieu thereof (Effective 182
January 1, 2020): 183
(b) (1) Except as otherwise provided under subdivision (2) of this 184
subsection or subsection (d) of this section, a covered person or a 185
covered person's authorized representative shall not file a request for 186
an external review or an expedited external review until the covered 187
person or the covered person's authorized representative has 188
exhausted the health carrier's internal grievance process. 189
(2) A health carrier may waive its internal grievance process and the 190
requirement for a covered person to exhaust such process prior to 191
filing a request for an external review or an expedited external review. 192
(3) (A) If a covered person or the covered person's authorized 193
representative files any grievance or requests any review of an adverse 194
determination pursuant to this section relating to the dispensation of a 195
drug, other than a schedule II or III controlled substance, prescribed by 196
a licensed participating provider, the health carrier shall issue 197
immediate electronic authorization to the covered person's pharmacy 198
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to dispense a temporary supply of the drug sufficient for the duration 199
of the grievance or review. The authorization shall include 200
confirmation of the availability of payment for such supply of such 201
drug. 202
(B) Not later than twenty-four hours after the health carrier has 203
issued such authorization to the pharmacy and prior to the pharmacy's 204
dispensation of such drug, such health carrier shall confirm with the 205
licensed participating provider the provider's concurrence with the 206
dispensing of such temporary supply of such drug. If such licensed 207
participating provider does not concur, the health carrier shall cancel 208
such authorization. 209
(C) The provisions of this subdivision shall not apply to a grievance 210
or review of an adverse determination under this section concerning 211
the substitution of a generic drug or another brand name drug for a 212
prescribed brand name drug unless the prescribing licensed 213
participating provider has specified that there shall be no substitution 214
for the specified brand name drug. 215
This act shall take effect as follows and shall amend the following
sections:
Section 1 January 1, 2020 38a-591d(b)
Sec. 2 January 1, 2020 38a-591e(c)
Sec. 3 January 1, 2020 38a-591f(b)
Sec. 4 January 1, 2020 38a-591g(b)
Statement of Purpose:
To require health insurance coverage of prescribed drugs during
adverse determination reviews and external review processes.
[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: SEN. LOONEY, 11th Dist.
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S.B. 37