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General Assembly Raised Bill No. 977
January Session, 2019
LCO No. 4872
Referred to Committee on INSURANCE AND REAL ESTATE
Introduced by:
(INS)
AN ACT CONCERNING EX PLANATIONS OF BENEFITS.
Be it enacted by the Senate and House of Representatives in General
Assembly convened:
Section 1. Section 38a-477d of the general statutes, as amended by 1
section 11 of public act 18-41, is repealed and the following is 2
substituted in lieu thereof (Effective January 1, 2020): 3
(a) Each insurer, health care center, hospital service corporation, 4
medical service corporation, fraternal benefit society or other entity 5
that delivers, issues for delivery, renews, amends or continues a health 6
insurance policy providing coverage of the type specified in 7
subdivisions (1), (2), (4), (11) and (12) of section 38a-469 in this state, 8
shall: 9
(1) Make available to consumers, in an easily readable, accessible 10
and understandable format: [, the] 11
(A) The following information for each such policy: 12
[(A)] (i) Any coverage exclusions; 13 Raised Bill No. 977
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[(B) any] (ii) Any restrictions on the use or quantity of a covered 14
benefit, including on prescription drugs or drugs administered in a 15
physician's office or a clinic; 16
[(C) a] (iii) A specific description of how prescription drugs are 17
included or excluded from any applicable deductible, including a 18
description of other out-of-pocket expenses that apply to such drugs; 19
[(D) the] (iv) The specific dollar amount of any copayment and the 20
percentage of any coinsurance imposed on each covered benefit, 21
including each covered prescription drug; and 22
[(E) information] (v) Information regarding any process available to 23
consumers, and all documents necessary, to seek coverage of a 24
noncovered outpatient prescription drug; and 25
(B) With respect to explanations of benefits issued pursuant to 26
subsection (d) of this section, a statement disclosing that each 27
consumer who is a covered individual and legally capable of 28
consenting to the provision of covered benefits under such policy may 29
specify that such insurer, center, corporation, society or entity shall: 30
(i) Not issue such explanations of benefits to such consumer; 31
(ii) Issue such explanations of benefits solely to such consumer if 32
such explanations of benefits contain confidential information 33
concerning covered benefits provided to such consumer; or 34
(iii) Use a method specified by such consumer to issue such 35
explanations of benefits to such consumer, and provide sufficient space 36
in the statement for such consumer to specify a mailing address, 37
electronic mail address or telephone number for such insurer, center, 38
corporation, society or entity, or a third-party administrator as defined 39
in section 38a-720, to use to contact such consumer regarding 40
confidential information concerning covered benefits provided to such 41
consumer. 42
(2) Make available to consumers a way to determine accurately: 43 Raised Bill No. 977
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(A) [whether] Whether a specific prescription drug is available 44
under such policy's drug formulary; 45
(B) [the] The coinsurance, copayment, deductible or other out-of-46
pocket expense applicable to such drug; 47
(C) [whether] Whether such drug is covered when dispensed by a 48
physician or a clinic; 49
(D) [whether] Whether such drug requires prior authorization or the 50
use of step therapy; 51
(E) [whether] Whether specific types of health care specialists are in-52
network; and 53
(F) [whether] Whether a specific health care provider or hospital is 54
in-network. 55
(b) (1) Each insurer, health care center, hospital service corporation, 56
medical service corporation, fraternal benefit society or other entity 57
shall make the information and statement required under subsection 58
(a) of this section available to consumers at the time of enrollment and 59
shall post such information and statement on its Internet web site. 60
(2) The Connecticut Health Insurance Exchange, established 61
pursuant to section 38a-1081, shall post links on its Internet web site to 62
such information and statement for each qualified health plan that is 63
offered or sold through the exchange. 64
(c) The Insurance Commissioner shall post links on the Insurance 65
Department's Internet web site to any on-line tools or calculators to 66
help consumers compare and evaluate health insurance policies and 67
plans. 68
(d) (1) Except as provided in subdivision (2) of this subsection, each 69
insurer, health care center, hospital service corporation, medical 70
service corporation, fraternal benefit society or other entity that 71
delivers, issues for delivery, renews, amends or continues a health 72 Raised Bill No. 977
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insurance policy described in subsection (a) of this section shall: 73
(A) Issue explanations of benefits to the consumers who are covered 74
individuals under the policy; and 75
(B) (i) Permit each consumer who is a covered individual under the 76
policy and legally capable of consenting to the provision of covered 77
benefits to specify the method that such insurer, center, corporation, 78
society or entity shall use to issue to such consumer explanations of 79
benefits concerning benefits provided to such consumer, which 80
method may include, but need not be limited to: 81
(I) Mailing such explanations of benefits to the policyholder's 82
mailing address, such consumer's mailing address or another mailing 83
address specified by such consumer; 84
(II) Sending such explanations of benefits by electronic means, 85
including, but not limited to, electronic mail; or 86
(III) Making such explanations of benefits available solely to such 87
consumer by electronic means, provided making such explanations of 88
benefits available solely to such consumer by electronic means 89
complies with all applicable federal and state laws and regulations 90
concerning data security, including, but not limited to, 45 CFR Part 160 91
and 45 CFR Part 164, Subparts A and C, as the same may be amended 92
from time to time. 93
(ii) Each method specified by a consumer pursuant to subparagraph 94
(B)(i) of this subdivision shall be valid until the consumer submits an 95
oral or written specification to the insurer, center, corporation, society 96
or entity for a different method. Such insurer, center, corporation, 97
society or entity shall comply with a specification under clauses (i) or 98
(ii) of this subparagraph not later than three calendar days after the 99
date of such specification, if such specification was made by electronic 100
or telephonic means, or seven days after the date such insurer, center, 101
corporation, society or entity received such specification by first-class 102
mail, provided such insurer, center, corporation, society or entity may 103 Raised Bill No. 977
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adhere to an electronic or telephonic specification and request that a 104
consumer send to such insurer, center, corporation, society or entity 105
written confirmation of such specification by first-class mail. 106
(iii) Each insurer, center, corporation, society or entity that receives 107
a specification from a consumer pursuant to subparagraph (B)(i) or 108
(B)(ii) of this subdivision shall provide the consumer who made such 109
specification with oral or written confirmation that such insurer, 110
center, corporation, society or entity received such specification, and 111
advise such consumer regarding the status of such specification if such 112
consumer contacts such insurer, center, corporation, society or entity 113
regarding such specification. 114
(2) Each consumer who is a covered individual under a policy 115
described in subsection (a) of this section, legally capable of consenting 116
to the provision of covered benefits and not financially liable for such 117
benefits may specify, either orally or in writing, that the insurer, 118
center, corporation, society or entity that delivered, issued for delivery, 119
renewed, amended or continued the policy not issue explanations of 120
benefits concerning such consumer pursuant to subdivision (1) of this 121
subsection. Such insurer, center, corporation, society or entity shall not 122
require such consumer to provide any explanation regarding the basis 123
for such consumer's specification, unless such explanation is required 124
by applicable law or pursuant to an order issued by a court of 125
competent jurisdiction. 126
(3) Each insurer, center, corporation, society or entity that delivers, 127
issues for delivery, renews, amends or continues a policy described in 128
subsection (a) of this section shall disclose to each consumer who is a 129
covered individual under the policy such consumer's ability to submit 130
specifications pursuant to subdivisions (1) and (2) of this subsection. 131
Such disclosure shall be in plain language and displayed or printed, as 132
applicable, clearly and conspicuously in all evidence of coverage 133
documents, privacy communications, explanations of benefits, and 134
Internet web sites that are maintained by such insurer, center, 135
corporation, society or entity and accessible to consumers in this state. 136 Raised Bill No. 977
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(4) Notwithstanding subdivisions (1) to (3), inclusive, of this 137
subsection, a health care provider may make arrangements with a 138
consumer for cost-sharing payments for covered benefits and shall 139
disclose such arrangements to the insurer, center, corporation, society 140
or entity that delivered, issued for delivery, renewed, amended or 141
continued the policy providing coverage to such consumer. 142
(5) No insurer, center, corporation, society or entity that is subject to 143
this subsection shall require a consumer or a policyholder to waive any 144
right to limit disclosure under this subsection as a precondition to 145
delivering, issuing for delivery, renewing, amending or continuing a 146
policy described in subsection (a) of this section to the consumer or 147
policyholder. Nothing in this subsection shall be construed to limit a 148
consumer's or policyholder's ability to request review of an adverse 149
determination. 150
This act shall take effect as follows and shall amend the following
sections:
Section 1 January 1, 2020 38a-477d
Statement of Purpose:
To require health carriers that deliver, issue for delivery, renew,
amend or continue certain health insurance policies in this state to
issue explanations of benefits to consumers in certain circumstances,
disclose information concerning explanations of benefits to consumers,
and require that explanations of benefits be maintained as confidential
in certain circumstances.
[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.]