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General Assembly Committee Bill No. 42
January Session, 2019
LCO No. 5694
Referred to Committee on INSURANCE AND REAL ESTATE
Introduced by:
(INS)
AN ACT CONCERNING CO INSURANCE, COPAYMENT S AND
DEDUCTIBLES AND CONT RACTING BY HEALTH CA RRIERS.
Be it enacted by the Senate and House of Representatives in General
Assembly convened:
Section 1. (NEW) (Effective January 1, 2020) (a) Notwithstanding any 1
provision of the general statutes and to the maximum extent permitted 2
by federal law, no individual or group health insurance policy 3
delivered, issued for delivery, renewed, amended or continued in this 4
state on or after January 1, 2020, providing coverage of the type 5
specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 of 6
the general statutes shall impose: 7
(1) A coinsurance or deductible for a covered benefit in an amount 8
that exceeds the lesser of: 9
(A) An amount calculated on the basis of the amount due and 10
payable for the covered benefit by the insurer, health care center, 11
fraternal benefit society, hospital service corporation, medical service 12
corporation or other entity that delivered, issued for delivery, 13
renewed, amended or continued such policy; 14 Committee Bill No. 42
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(B) An amount calculated on the basis of the amount charged for the 15
covered benefit by the provider or vendor, less any discount for such 16
covered benefit and any amount due to, or charged by, an entity if 17
such entity is affiliated with, or owned or controlled by, the insurer, 18
health care center, fraternal benefit society, hospital service 19
corporation, medical service corporation or other entity that delivered, 20
issued for delivery, renewed, amended or continued such policy; or 21
(C) The amount that the insured would have paid for the covered 22
benefit without regard to such policy; or 23
(2) A copayment in an amount that the insured would have paid for 24
the covered benefit without regard to such policy. 25
(b) Any violation of this section shall constitute an unfair trade 26
practice in violation of chapter 735a of the general statutes. 27
Sec. 2. (NEW) (Effective January 1, 2020) Notwithstanding any 28
provision of the general statutes, and to the maximum extent 29
permitted by applicable law, no contract entered into or amended by a 30
health carrier, as defined in section 38a-591a of the general statutes, on 31
or after January 1, 2020, shall permit or require any party to such 32
contract to violate the fiduciary duties that the health carrier owes to 33
its insureds. 34
Sec. 3. Section 20-7f of the general statutes is repealed and the 35
following is substituted in lieu thereof (Effective January 1, 2020): 36
(a) For purposes of this section: 37
(1) "Request payment" includes, but is not limited to, submitting a 38
bill for services not actually owed or submitting for such services an 39
invoice or other communication detailing the cost of the services that is 40
not clearly marked with the phrase "This is not a bill". 41
(2) "Health care provider" means a person licensed to provide health 42
care services under chapters 370 to 373, inclusive, chapters 375 to 383b, 43 Committee Bill No. 42
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inclusive, chapters 384a to 384c, inclusive, or chapter 400j. 44
(3) "Enrollee" means a person who has contracted for or who 45
participates in a health care plan for such enrollee or such enrollee's 46
eligible dependents. 47
(4) ["Coinsurance, copayment, deductible or other out-of-pocket 48
expense"] "Coinsurance, copayment or deductible" means the portion 49
of a charge for services covered by a health care plan that, under the 50
plan's terms, it is the obligation of the enrollee to pay. 51
(5) "Health care plan" has the same meaning as provided in 52
subsection (a) of section 38a-477aa. 53
(6) "Health carrier" has the same meaning as provided in subsection 54
(a) of section 38a-477aa. 55
(7) "Emergency services" has the same meaning as provided in 56
subsection (a) of section 38a-477aa. 57
(b) It shall be an unfair trade practice in violation of chapter 735a for 58
any health care provider to request payment from an enrollee: [, other] 59
(1) Other than a coinsurance, copayment [,] or deductible, [or other 60
out-of-pocket expense,] for [(1)] (A) health care services or a facility 61
fee, as defined in section 19a-508c, covered under a health care plan, 62
[(2)] (B) emergency services covered under a health care plan and 63
rendered by an out-of-network health care provider, or [(3)] (C) a 64
surprise bill, as defined in section 38a-477aa; [.] or 65
(2) For a coinsurance, copayment or deductible in an amount that 66
exceeds the amount calculated pursuant to section 1 of this act. 67
(c) It shall be an unfair trade practice in violation of chapter 735a for 68
any health care provider to report to a credit reporting agency an 69
enrollee's failure to pay a bill for the services, facility fee or surprise bill 70
as set forth in subdivision (1) of subsection (b) of this section, when a 71 Committee Bill No. 42
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health carrier has primary responsibility for payment of such services, 72
fees or bills. 73
Sec. 4. Subdivision (3) of subsection (c) of section 38a-193 of the 74
general statutes is repealed and the following is substituted in lieu 75
thereof (Effective January 1, 2020): 76
(3) No participating provider, or agent, trustee or assignee thereof, 77
may: (A) Maintain any action at law against a subscriber or enrollee to 78
collect sums owed by the health care center; (B) request payment from 79
a subscriber or enrollee for such sums; (C) request payment from a 80
subscriber or enrollee for covered emergency services that are 81
provided by an out-of-network provider; or (D) request payment from 82
a subscriber or enrollee for a surprise bill, as defined in section 38a-83
477aa, as amended by this act. For purposes of this subdivision 84
"request payment" includes, but is not limited to, submitting a bill for 85
services not actually owed or submitting for such services an invoice 86
or other communication detailing the cost of the services that is not 87
clearly marked with the phrase "THIS IS NOT A BILL". The contract 88
between a health care center and a participating provider shall inform 89
the participating provider that pursuant to section 20-7f, as amended 90
by this act, it is an unfair trade practice in violation of chapter 735a for 91
any health care provider to request payment from a subscriber or an 92
enrollee, other than a coinsurance, copayment [,] or deductible, [or 93
other out-of-pocket expense,] for covered medical or emergency 94
services or facility fees, as defined in section 19a-508c, or surprise bills, 95
or to report to a credit reporting agency an enrollee's failure to pay a 96
bill for such services when a health care center has primary 97
responsibility for payment of such services, fees or bills. 98
Sec. 5. Section 38a-478j of the general statutes is repealed and the 99
following is substituted in lieu thereof (Effective January 1, 2020): 100
Each managed care plan that requires a deductible or percentage 101
coinsurance payment by the insured shall calculate the insured's 102
deductible or coinsurance payment on the lesser of the provider's or 103 Committee Bill No. 42
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vendor's charges for the goods or services or the amount payable by 104
the managed care organization or a subcontractor of such managed 105
care organization for such goods or services, except as otherwise 106
required by the laws of a foreign state when applicable to providers, 107
vendors or patients in such foreign state. 108
This act shall take effect as follows and shall amend the following
sections:
Section 1 January 1, 2020 New section
Sec. 2 January 1, 2020 New section
Sec. 3 January 1, 2020 20-7f
Sec. 4 January 1, 2020 38a-193(c)(3)
Sec. 5 January 1, 2020 38a-478j
INS Joint Favorable
JUD Joint Favorable