LCO \\PRDFS1\SCOUSERS\FORZANOF\WS\2019SB-00977-R01-
SB.docx
1 of 7
General Assembly Substitute Bill No. 977
January Session, 2019
AN ACT CONCERNING EX PLANATIONS OF BENEFI TS.
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section 11 of public act 18-41, is repealed and the following is 2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
[(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 Substitute Bill No. 977
LCO {\\PRDFS1\SCOUSERS\FORZANOF\WS\2019SB-00977-
R01-SB.docx }
2 of 7
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
(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 Substitute Bill No. 977
LCO {\\PRDFS1\SCOUSERS\FORZANOF\WS\2019SB-00977-
R01-SB.docx }
3 of 7
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
insurance policy described in subsection (a) of this section shall: 73
(A) Issue an explanation of benefits to each consumer who is a 74 Substitute Bill No. 977
LCO {\\PRDFS1\SCOUSERS\FORZANOF\WS\2019SB-00977-
R01-SB.docx }
4 of 7
covered individual 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 an explanation of benefits 79
concerning benefits provided to such consumer, which method may 80
include, but need not be limited to: 81
(I) Mailing such explanation of benefits to the policyholder's mailing 82
address, such consumer's mailing address or another mailing address 83
specified by such consumer; 84
(II) Sending such explanation of benefits by electronic means, 85
including, but not limited to, electronic mail; or 86
(III) Making such explanation of benefits available solely to such 87
consumer by electronic means, provided making such explanation 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 91
160, as amended from time to time, and 45 CFR Part 164, Subparts A 92
and C, as amended 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 this clause 98
and clause (i) of this subparagraph not later than three calendar days 99
after the date of such specification, if such specification was made by 100
electronic or telephonic means, or seven days after the date such 101
insurer, center, corporation, society or entity received such 102
specification by first-class mail, except that such insurer, center, 103
corporation, society or entity may adhere to an electronic or telephonic 104
specification and request that a consumer send to such insurer, center, 105 Substitute Bill No. 977
LCO {\\PRDFS1\SCOUSERS\FORZANOF\WS\2019SB-00977-
R01-SB.docx }
5 of 7
corporation, society or entity written confirmation of such specification 106
by first-class mail. 107
(iii) Each insurer, center, corporation, society or entity that receives 108
a specification from a consumer pursuant to subparagraph (B)(i) or 109
(B)(ii) of this subdivision shall provide the consumer who made such 110
specification with oral or written confirmation that such insurer, 111
center, corporation, society or entity received such specification, and 112
advise such consumer regarding the status of such specification if such 113
consumer contacts such insurer, center, corporation, society or entity 114
regarding such specification. 115
(2) Each consumer who is a covered individual under a policy 116
described in subsection (a) of this section, is legally capable of 117
consenting to the provision of covered benefits and is not financially 118
liable for such benefits may specify, either orally or in writing, that the 119
insurer, center, corporation, society or entity that delivered, issued for 120
delivery, renewed, amended or continued the policy not issue an 121
explanation of benefits concerning such consumer pursuant to 122
subdivision (1) of this subsection. Such insurer, center, corporation, 123
society or entity shall not require such consumer to provide any 124
explanation regarding the basis for such consumer's specification, 125
unless such explanation is required by applicable law or pursuant to 126
an order issued by a court of competent jurisdiction. 127
(3) Each insurer, center, corporation, society or entity that delivers, 128
issues for delivery, renews, amends or continues a policy described in 129
subsection (a) of this section shall disclose to each consumer who is a 130
covered individual under the policy such consumer's ability to submit 131
specifications pursuant to subdivisions (1) and (2) of this subsection. 132
Such disclosure shall be in plain language and displayed or printed, as 133
applicable, clearly and conspicuously in all evidence of coverage 134
documents, privacy communications, explanations of benefits, and 135
Internet web sites that are maintained by such insurer, center, 136
corporation, society or entity and accessible to consumers in this state. 137 Substitute Bill No. 977
LCO {\\PRDFS1\SCOUSERS\FORZANOF\WS\2019SB-00977-
R01-SB.docx }
6 of 7
(4) Notwithstanding subdivisions (1) to (3), inclusive, of this 138
subsection, a health care provider may make arrangements with a 139
consumer for cost-sharing payments for covered benefits and shall 140
disclose such arrangements to the insurer, center, corporation, society 141
or entity that delivered, issued for delivery, renewed, amended or 142
continued the policy providing coverage to such consumer. 143
(5) No insurer, center, corporation, society or entity that is subject to 144
this subsection shall require a consumer or policyholder to waive any 145
right to limit disclosure under this subsection as a precondition to 146
delivering, issuing for delivery, renewing, amending or continuing a 147
policy described in subsection (a) of this section to the consumer or 148
policyholder. Nothing in this subsection shall be construed to limit a 149
consumer's or policyholder's ability to request review of an adverse 150
determination. 151
This act shall take effect as follows and shall amend the following
sections:
Section 1 January 1, 2020 38a-477d
Statement of Legislative Commissioners:
In Subsec. (d)(1)(A), "an" was inserted before "explanations",
"explanation" was substituted for "explanations", "each" was
substituted for "the", "consumer" was substituted for "consumers", "is
a" was substituted for "are" and "individual" was substituted for
"individuals" for consistency; in Subsec. (d)(1)(B)(i), "an explanation"
was substituted for "to such consumer explanations" for consistency
and conciseness; in Subsecs. (d)(1)(B)(i)(I) and (II), "explanation" was
substituted for "explanations" for consistency; in Subsec.
(d)(1)(B)(i)(III), "explanation" was substituted for "explanations", ", as
amended from time to time," was inserted after "45 CFR Part 160" and
"the same may be" was deleted for consistency; in Subsec. (d)(1)(B)(ii),
"this clause and clause (i)" was substituted for "clauses (i) or (ii)" and
"except that" was substituted for "provided" for consistency; in Subsec.
(d)(2), "is" was inserted before "legally" and "not financially" for clarity,
and "an explanation" was substituted for "explanations" for
consistency; and in Subsec. (d)(5), "policyholder" was substituted for "a
policyholder" for conciseness. Substitute Bill No. 977
LCO {\\PRDFS1\SCOUSERS\FORZANOF\WS\2019SB-00977-
R01-SB.docx }
7 of 7
INS Joint Favorable Subst. -LCO