Connecticut 2019 Regular Session

Connecticut Senate Bill SB00037 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
1	1
2	2
	3	+	LCO No. 920 1 of 1
3	4
4		-	LCO No. 5682 1 of 9
5		-
6		-	General Assembly Committee Bill No. 37
	5	+	General Assembly Proposed Bill No. 37
7	6		January Session, 2019
8		-	LCO No. ~~5682~~
	7	+	LCO No. 920
9	8
10	9
11	10		Referred to Committee on INSURANCE AND REAL ESTATE
12	11
13	12
14	13		Introduced by:
15		-	~~(INS)~~
	14	+	SEN. LOONEY, 11th Dist.
16	15
17	16
18	17
19		-	AN ACT REQUIRING ~~HEA LTH~~ INSURANCE COVERAGE ~~O F A~~
20		-	PRESCRIBED ~~DRUG DURI NG~~ ADVERSE ~~DETERMINA TION REVIEWS~~
21		-	AND EXTERNAL REVIEW PROCESSES.
	18	+	AN ACT REQUIRING HEALTH INSURANCE COVERAGE OF
	19	+	PRESCRIBED DRUGS DURING ADVERSE DETERMINATION
	20	+	REVIEWS AND EXTERNAL REVIEW PROCESSES.
22	21		Be it enacted by the Senate and House of Representatives in General
23	22		Assembly convened:
24	23
25		-	Section 1. Subsection (b) of section 38a-591d of the general statutes is 1
26		-	repealed and the following is substituted in lieu thereof (Effective 2
27		-	January 1, 2020): 3
28		-	(b) With respect to a nonurgent care request: 4
29		-	(1) (A) For a prospective or concurrent review request, a health 5
30		-	carrier shall make a determination within a reasonable period of time 6
31		-	appropriate to the covered person's medical condition, but not later 7
32		-	than fifteen calendar days after the date the health carrier receives such 8
33		-	request, and shall notify the covered person and, if applicable, the 9
34		-	covered person's authorized representative of such determination, 10
35		-	whether or not the carrier certifies the provision of the benefit. 11
36		-	(B) If the review under subparagraph (A) of this subdivision is a 12
37		-	review of a grievance involving a concurrent review request, pursuant 13
38		-	to 45 CFR 147.136, as amended from time to time, the treatment shall 14
39		-	Committee Bill No. 37
40		-
41		-
42		-	LCO No. 5682 2 of 9
43		-
44		-	be continued without liability to the covered person until the covered 15
45		-	person has been notified of the review decision. 16
46		-	(C) (i) Notwithstanding subparagraph (B) of this subdivision, if a 17
47		-	covered person or the covered person's authorized representative files 18
48		-	any grievance or requests any review of an adverse determination 19
49		-	pursuant to this section relating to the dispensation of a drug, other 20
50		-	than a schedule II or III controlled substance, prescribed by a licensed 21
51		-	participating provider, the health carrier shall issue immediate 22
52		-	electronic authorization to the covered person's pharmacy to dispense 23
53		-	a temporary supply of the drug sufficient for the duration of the 24
54		-	grievance or review. The authorization shall include confirmation of 25
55		-	the availability of payment for such supply of such drug. 26
56		-	(ii) Not later than twenty-four hours after the health carrier has 27
57		-	issued such authorization to the pharmacy and prior to the pharmacy's 28
58		-	dispensation of such drug, such health carrier shall confirm with the 29
59		-	licensed participating provider the provider's concurrence with the 30
60		-	dispensing of such temporary supply of such drug. If such licensed 31
61		-	participating provider does not concur, the health carrier shall cancel 32
62		-	such authorization. 33
63		-	(iii) The provisions of this subparagraph shall not apply to a 34
64		-	grievance or review of an adverse determination under this section 35
65		-	concerning the substitution of a generic drug or another brand name 36
66		-	drug for a prescribed brand name drug unless the prescribing licensed 37
67		-	participating provider has specified that there shall be no substitution 38
68		-	for the specified brand name drug. 39
69		-	(2) For a retrospective review request, a health carrier shall make a 40
70		-	determination within a reasonable period of time, but not later than 41
71		-	thirty calendar days after the date the health carrier receives such 42
72		-	request. 43
73		-	(3) The time periods specified in subdivisions (1) and (2) of this 44
74		-	subsection may be extended once by the health carrier for up to fifteen 45
75		-	Committee Bill No. 37
76		-
77		-
78		-	LCO No. 5682 3 of 9
79		-
80		-	calendar days, provided the health carrier: 46
81		-	(A) Determines that an extension is necessary due to circumstances 47
82		-	beyond the health carrier's control; and 48
83		-	(B) Notifies the covered person and, if applicable, the covered 49
84		-	person's authorized representative prior to the expiration of the initial 50
85		-	time period, of the circumstances requiring the extension of time and 51
86		-	the date by which the health carrier expects to make a determination. 52
87		-	(4) (A) If the extension pursuant to subdivision (3) of this subsection 53
88		-	is necessary due to the failure of the covered person or the covered 54
89		-	person's authorized representative to provide information necessary to 55
90		-	make a determination on the request, the health carrier shall: 56
91		-	(i) Specifically describe in the notice of extension the required 57
92		-	information necessary to complete the request; and 58
93		-	(ii) Provide the covered person and, if applicable, the covered 59
94		-	person's authorized representative with not less than forty-five 60
95		-	calendar days after the date of receipt of the notice to provide the 61
96		-	specified information. 62
97		-	(B) If the covered person or the covered person's authorized 63
98		-	representative fails to submit the specified information before the end 64
99		-	of the period of the extension, the health carrier may deny certification 65
100		-	of the benefit requested. 66
101		-	Sec. 2. Subsection (c) of section 38a-591e of the general statutes is 67
102		-	repealed and the following is substituted in lieu thereof (Effective 68
103		-	January 1, 2020): 69
104		-	(c) (1) (A) When conducting a review of an adverse determination 70
105		-	under this section, the health carrier shall ensure that such review is 71
106		-	conducted in a manner to ensure the independence and impartiality of 72
107		-	the clinical peer or peers involved in making the review decision. 73
108		-	Committee Bill No. 37
109		-
110		-
111		-	LCO No. 5682 4 of 9
112		-
113		-	(B) If the adverse determination involves utilization review, the 74
114		-	health carrier shall designate an appropriate clinical peer or peers to 75
115		-	review such adverse determination. Such clinical peer or peers shall 76
116		-	not have been involved in the initial adverse determination. 77
117		-	(C) The clinical peer or peers conducting a review under this section 78
118		-	shall take into consideration all comments, documents, records and 79
119		-	other information relevant to the covered person's benefit request that 80
120		-	is the subject of the adverse determination under review, that are 81
121		-	submitted by the covered person or the covered person's authorized 82
122		-	representative, regardless of whether such information was submitted 83
123		-	or considered in making the initial adverse determination. 84
124		-	(D) Prior to issuing a decision, the health carrier shall provide free 85
125		-	of charge, by facsimile, electronic means or any other expeditious 86
126		-	method available, to the covered person or the covered person's 87
127		-	authorized representative, as applicable, any new or additional 88
128		-	documents, communications, information and evidence relied upon 89
129		-	and any new or additional scientific or clinical rationale used by the 90
130		-	health carrier in connection with the grievance. Such documents, 91
131		-	communications, information, evidence and rationale shall be 92
132		-	provided sufficiently in advance of the date the health carrier is 93
133		-	required to issue a decision to permit the covered person or the 94
134		-	covered person's authorized representative, as applicable, a reasonable 95
135		-	opportunity to respond prior to such date. 96
136		-	(2) If the review under subdivision (1) of this subsection is an 97
137		-	expedited review, all necessary information, including the health 98
138		-	carrier's decision, shall be transmitted between the health carrier and 99
139		-	the covered person or the covered person's authorized representative, 100
140		-	as applicable, by telephone, facsimile, electronic means or any other 101
141		-	expeditious method available. 102
142		-	(3) If the review under subdivision (1) of this subsection is an 103
143		-	expedited review of a grievance involving an adverse determination of 104
144		-	a concurrent review request, pursuant to 45 CFR 147.136, as amended 105
145		-	Committee Bill No. 37
146		-
147		-
148		-	LCO No. 5682 5 of 9
149		-
150		-	from time to time, the treatment shall be continued without liability to 106
151		-	the covered person until the covered person has been notified of the 107
152		-	review decision. 108
153		-	(4) (A) Notwithstanding subdivision (3) of this subsection, if a 109
154		-	covered person or the covered person's authorized representative files 110
155		-	any grievance or requests any review of an adverse determination 111
156		-	pursuant to this section relating to the dispensation of a drug, other 112
157		-	than a schedule II or III controlled substance, prescribed by a licensed 113
158		-	participating provider, the health carrier shall issue immediate 114
159		-	electronic authorization to the covered person's pharmacy to dispense 115
160		-	a temporary supply of the drug sufficient for the duration of the 116
161		-	grievance or review. The authorization shall include confirmation of 117
162		-	the availability of payment for such supply of such drug. 118
163		-	(B) Not later than twenty-four hours after the health carrier has 119
164		-	issued such authorization to the pharmacy and prior to the pharmacy's 120
165		-	dispensation of such drug, such health carrier shall confirm with the 121
166		-	licensed participating provider the provider's concurrence with the 122
167		-	dispensing of such temporary supply of such drug. If such licensed 123
168		-	participating provider does not concur, the health carrier shall cancel 124
169		-	such authorization. 125
170		-	(C) The provisions of this subdivision shall not apply to a grievance 126
171		-	or review of an adverse determination under this section concerning 127
172		-	the substitution of a generic drug or another brand name drug for a 128
173		-	prescribed brand name drug unless the prescribing licensed 129
174		-	participating provider has specified that there shall be no substitution 130
175		-	for the specified brand name drug. 131
176		-	Sec. 3. Subsection (b) of section 38a-591f of the general statutes is 132
177		-	repealed and the following is substituted in lieu thereof (Effective 133
178		-	January 1, 2020): 134
179		-	(b) (1) A covered person or the covered person's authorized 135
180		-	representative may file a grievance of an adverse determination that 136
181		-	Committee Bill No. 37
182		-
183		-
184		-	LCO No. 5682 6 of 9
185		-
186		-	was not based on medical necessity with the health carrier not later 137
187		-	than one hundred eighty calendar days after the covered person or the 138
188		-	covered person's representative, as applicable, receives the notice of an 139
189		-	adverse determination. 140
190		-	(2) (A) If a covered person or the covered person's authorized 141
191		-	representative files any grievance or requests any review of an adverse 142
192		-	determination pursuant to this section relating to the dispensation of a 143
193		-	drug, other than a schedule II or III controlled substance, prescribed by 144
194		-	a licensed participating provider, the health carrier shall issue 145
195		-	immediate electronic authorization to the covered person's pharmacy 146
196		-	to prescribe a temporary supply of the drug sufficient for the duration 147
197		-	of the grievance or review. The a uthorization shall include 148
198		-	confirmation of the availability of payment for such supply of such 149
199		-	drug. 150
200		-	(B) Not later than twenty-four hours after the health carrier has 151
201		-	issued such authorization to the pharmacy and prior to the pharmacy's 152
202		-	dispensation of such drug, such health carrier shall confirm with the 153
203		-	licensed participating provider the provider's concurrence with the 154
204		-	dispensing of such temporary supply of such drug. If such licensed 155
205		-	participating provider does not concur, the health carrier shall cancel 156
206		-	such authorization. 157
207		-	(C) The provisions of this subdivision shall not apply to a grievance 158
208		-	or review of an adverse determination under this section concerning 159
209		-	the substitution of a generic drug or another brand name drug for a 160
210		-	prescribed brand name drug unless the prescribing licensed 161
211		-	participating provider has specified that there shall be no substitution 162
212		-	for the specified brand name drug. 163
213		-	[(2)] (3) The health carrier shall notify the covered person and, if 164
214		-	applicable, the covered person's authorized representative not later 165
215		-	than three business days after the health carrier receives a grievance 166
216		-	the covered person or the covered person's authorized representative, 167
217		-	as applicable, is entitled to submit written material to the health carrier 168
218		-	Committee Bill No. 37
219		-
220		-
221		-	LCO No. 5682 7 of 9
222		-
223		-	to be considered when conducting a review of the grievance. 169
224		-	[(3)] (4) (A) Upon receipt of a grievance, a health carrier shall 170
225		-	designate an individual or individuals to conduct a review of the 171
226		-	grievance. 172
227		-	(B) The health carrier shall not designate the same individual or 173
228		-	individuals who denied the claim or handled the matter that is the 174
229		-	subject of the grievance to conduct the review of the grievance. 175
230		-	(C) The health carrier shall provide the covered person and, if 176
231		-	applicable, the covered person's authorized representative with the 177
232		-	name, address and telephone number of the individual or the 178
233		-	organizational unit designated to coordinate the review on behalf of 179
234		-	the health carrier. 180
235		-	Sec. 4. Subsection (b) of section 38a-591g of the general statutes is 181
236		-	repealed and the following is substituted in lieu thereof (Effective 182
237		-	January 1, 2020): 183
238		-	(b) (1) Except as otherwise provided under subdivision (2) of this 184
239		-	subsection or subsection (d) of this section, a covered person or a 185
240		-	covered person's authorized representative shall not file a request for 186
241		-	an external review or an expedited external review until the covered 187
242		-	person or the covered person's authorized representative has 188
243		-	exhausted the health carrier's internal grievance process. 189
244		-	(2) A health carrier may waive its internal grievance process and the 190
245		-	requirement for a covered person to exhaust such process prior to 191
246		-	filing a request for an external review or an expedited external review. 192
247		-	(3) (A) If a covered person or the covered person's authorized 193
248		-	representative files any grievance or requests any review of an adverse 194
249		-	determination pursuant to this section relating to the dispensation of a 195
250		-	drug, other than a schedule II or III controlled substance, prescribed by 196
251		-	a licensed participating provider, the health carrier shall issue 197
252		-	immediate electronic authorization to the covered person's pharmacy 198
253		-	Committee Bill No. 37
254		-
255		-
256		-	LCO No. 5682 8 of 9
257		-
258		-	to dispense a temporary supply of the drug sufficient for the duration 199
259		-	of the grievance or review. The authorization shall include 200
260		-	confirmation of the availability of payment for such supply of such 201
261		-	drug. 202
262		-	(B) Not later than twenty-four hours after the health carrier has 203
263		-	issued such authorization to the pharmacy and prior to the pharmacy's 204
264		-	dispensation of such drug, such health carrier shall confirm with the 205
265		-	licensed participating provider the provider's concurrence with the 206
266		-	dispensing of such temporary supply of such drug. If such licensed 207
267		-	participating provider does not concur, the health carrier shall cancel 208
268		-	such authorization. 209
269		-	(C) The provisions of this subdivision shall not apply to a grievance 210
270		-	or review of an adverse determination under this section concerning 211
271		-	the substitution of a generic drug or another brand name drug for a 212
272		-	prescribed brand name drug unless the prescribing licensed 213
273		-	participating provider has specified that there shall be no substitution 214
274		-	for the specified brand name drug. 215
275		-	This act shall take effect as follows and shall amend the following
276		-	sections:
277		-
278		-	Section 1 January 1, 2020 38a-591d(b)
279		-	Sec. 2 January 1, 2020 38a-591e(c)
280		-	Sec. 3 January 1, 2020 38a-591f(b)
281		-	Sec. 4 January 1, 2020 38a-591g(b)
282		-
	24	+	That sections 38a-591d, 38a-591e, 38a-591f and 38a-591g of the 1
	25	+	general statutes be amended to require health insurance coverage of 2
	26	+	prescribed drugs during adverse determination reviews and external 3
	27	+	review processes. 4
283	28		Statement of Purpose:
284	29		To require health insurance coverage of prescribed drugs during
285	30		adverse determination reviews and external review processes.
286		-	[Proposed deletions are enclosed in brackets. Proposed additions are indicated by underline,
287		-	except that when the entire text of a bill or resolution or a section of a bill or resolution is new, it is
288		-	not underlined.]
289		-
290		-	Co-Sponsors: SEN. LOONEY, 11th Dist.
291		-
292		-	Committee Bill No. 37
293		-
294		-
295		-	LCO No. 5682 9 of 9
296		-
297		-	S.B. 37
298		-
299		-