Connecticut 2020 Regular Session

Connecticut Senate Bill SB00341 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
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2	2
3	3	LCO No. 2033 1 of 18
4	4
5	5	General Assembly Raised Bill No. 341
6	6	February Session, 2020
7	7	LCO No. 2033
8	8
9	9
10	10	Referred to Committee on INSURANCE AND REAL ESTATE
11	11
12	12
13	13	Introduced by:
14	14	(INS)
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16	16
17	17
18	18
19	19	AN ACT CONCERNING PA RTICIPATION BY COVERED PERSONS,
20	20	AUTHORIZED REPRESENTATIVES AND HEALTH CARE
21	21	PROFESSIONALS IN UTILIZATION REVIEWS.
22	22	Be it enacted by the Senate and House of Representatives in General
23	23	Assembly convened:
24	24
25	25	Section 1. (NEW) (Effective January 1, 2021) Each health care 1
26	26	professional who submits an urgent care request for a covered person 2
27	27	shall provide, at least annually, a written notice to the covered person 3
28	28	or the covered person's authorized representative, as applicable, 4
29	29	disclosing the right to submit the covered person's story pursuant to 5
30	30	subsection (c) of section 38a-591d of the general statutes, as amended by 6
31	31	this act. For the purposes of this section, "authorized representative", 7
32	32	"health care professional", "covered person's story" and "urgent care 8
33	33	request" have the same meanings as provided in section 38a-591a of the 9
34	34	general statutes, as amended by this act. 10
35	35	Sec. 2. Section 38a-591a of the general statutes is repealed and the 11
36	36	following is substituted in lieu thereof (Effective January 1, 2021): 12
37	37	As used in this section and sections 38a-591b to 38a-591n, inclusive, 13
38	38	as amended by this act: 14 Raised Bill No. 341
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40	40
41	41
42	42	LCO No. 2033 2 of 18
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44	44	(1) "Adverse determination" means: 15
45	45	(A) The denial, reduction, termination or failure to provide or make 16
46	46	payment, in whole or in part, for a benefit under the health carrier's 17
47	47	health benefit plan requested by a covered person or a covered person's 18
48	48	treating health care professional, based on a determination by a health 19
49	49	carrier or its designee utilization review company: 20
50	50	(i) That, based upon the information provided, (I) upon application 21
51	51	of any utilization review technique, such benefit does not meet the 22
52	52	health carrier's requirements for medical necessity, appropriateness, 23
53	53	health care setting, level of care or effectiveness, or (II) is determined to 24
54	54	be experimental or investigational; 25
55	55	(ii) Of a covered person's eligibility to participate in the health 26
56	56	carrier's health benefit plan; or 27
57	57	(B) Any prospective review, concurrent review or retrospective 28
58	58	review determination that denies, reduces or terminates or fails to 29
59	59	provide or make payment, in whole or in part, for a benefit under the 30
60	60	health carrier's health benefit plan requested by a covered person or a 31
61	61	covered person's treating health care professional. 32
62	62	"Adverse determination" includes a rescission of coverage 33
63	63	determination for grievance purposes. 34
64	64	(2) "Authorized representative" means: 35
65	65	(A) A person to whom a covered person has given express written 36
66	66	consent to represent the covered person for the purposes of this section 37
67	67	and sections 38a-591b to 38a-591n, inclusive, as amended by this act; 38
68	68	(B) A person authorized by law to provide substituted consent for a 39
69	69	covered person; 40
70	70	(C) A family member of the covered person or the covered person's 41
71	71	treating health care professional when the covered person is unable to 42
72	72	provide consent; 43 Raised Bill No. 341
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78	78	(D) A health care professional when the covered person's health 44
79	79	benefit plan requires that a request for a benefit under the plan be 45
80	80	initiated by the health care professional; or 46
81	81	(E) In the case of an urgent care request, a health care professional 47
82	82	with knowledge of the covered person's medical condition. 48
83	83	(3) "Best evidence" means evidence based on (A) randomized clinical 49
84	84	trials, (B) if randomized clinical trials are not available, cohort studies or 50
85	85	case-control studies, (C) if such trials and studies are not available, case-51
86	86	series, or (D) if such trials, studies and case-series are not available, 52
87	87	expert opinion. 53
88	88	(4) "Case-control study" means a retrospective evaluation of two 54
89	89	groups of patients with different outcomes to determine which specific 55
90	90	interventions the patients received. 56
91	91	(5) "Case-series" means an evaluation of a series of patients with a 57
92	92	particular outcome, without the use of a control group. 58
93	93	(6) "Certification" means a determination by a health carrier or its 59
94	94	designee utilization review company that a request for a benefit under 60
95	95	the health carrier's health benefit plan has been reviewed and, based on 61
96	96	the information provided, satisfies the health carrier's requirements for 62
97	97	medical necessity, appropriateness, health care setting, level of care and 63
98	98	effectiveness. 64
99	99	(7) "Clinical peer" means a physician or other health care professional 65
100	100	who (A) holds a nonrestricted license in a state of the United States and 66
101	101	in the same or similar specialty as typically manages the medical 67
102	102	condition, procedure or treatment under review, and (B) for a review 68
103	103	specified under subparagraph (B) or (C) of subdivision (38) of this 69
104	104	section concerning (i) a child or adolescent substance use disorder or a 70
105	105	child or adolescent mental disorder, holds (I) a national board 71
106	106	certification in child and adolescent psychiatry, or (II) a doctoral level 72
107	107	psychology degree with training and clinical experience in the treatment 73
108	108	of child and adolescent substance use disorder or child and adolescent 74 Raised Bill No. 341
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110	110
111	111
112	112	LCO No. 2033 4 of 18
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114	114	mental disorder, as applicable, or (ii) an adult substance use disorder or 75
115	115	an adult mental disorder, holds (I) a national board certification in 76
116	116	psychiatry, or (II) a doctoral level psychology degree with training and 77
117	117	clinical experience in the treatment of adult substance use disorders or 78
118	118	adult mental disorders, as applicable. 79
119	119	(8) "Clinical review criteria" means the written screening procedures, 80
120	120	decision abstracts, clinical protocols and practice guidelines used by the 81
121	121	health carrier to determine the medical necessity and appropriateness 82
122	122	of health care services. 83
123	123	(9) "Cohort study" means a prospective evaluation of two groups of 84
124	124	patients with only one group of patients receiving a specific intervention 85
125	125	or specific interventions. 86
126	126	[(10) "Commissioner" means the Insurance Commissioner.] 87
127	127	[(11)] (10) "Concurrent review" means utilization review conducted 88
128	128	during a patient's stay or course of treatment in a facility, the office of a 89
129	129	health care professional or other inpatient or outpatient health care 90
130	130	setting, including home care. 91
131	131	[(12)] (11) "Covered benefits" or "benefits" means health care services 92
132	132	to which a covered person is entitled under the terms of a health benefit 93
133	133	plan. 94
134	134	[(13)] (12) "Covered person" means a policyholder, subscriber, 95
135	135	enrollee or other individual participating in a health benefit plan. 96
136	136	(13) "Covered person's story" means a written statement by a covered 97
137	137	person or a covered person's authorized representative containing any 98
138	138	information that the covered person or the covered person's authorized 99
139	139	representative, as applicable, wants a utilization review company to 100
140	140	consider when reviewing a nonurgent care request or an urgent care 101
141	141	request, as applicable. 102
142	142	(14) "Emergency medical condition" means a medical condition 103
143	143	manifesting itself by acute symptoms of sufficient severity, including 104 Raised Bill No. 341
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145	145
146	146
147	147	LCO No. 2033 5 of 18
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149	149	severe pain, such that a prudent layperson with an average knowledge 105
150	150	of health and medicine, acting reasonably, would have believed that the 106
151	151	absence of immediate medical attention would result in serious 107
152	152	impairment to bodily functions or serious dysfunction of a bodily organ 108
153	153	or part, or would place the person's health or, with respect to a pregnant 109
154	154	woman, the health of the woman or her unborn child, in serious 110
155	155	jeopardy. 111
156	156	(15) "Emergency services" means, with respect to an emergency 112
157	157	medical condition: 113
158	158	(A) A medical screening examination that is within the capability of 114
159	159	the emergency department of a hospital, including ancillary services 115
160	160	routinely available to the emergency department to evaluate such 116
161	161	emergency medical condition; and 117
162	162	(B) Such further medical examination and treatment, to the extent 118
163	163	they are within the capability of the staff and facilities available at a 119
164	164	hospital, to stabilize a patient. 120
165	165	(16) "Evidence-based standard" means the conscientious, explicit and 121
166	166	judicious use of the current best evidence based on an overall systematic 122
167	167	review of medical research when making determinations about the care 123
168	168	of individual patients. 124
169	169	(17) "Expert opinion" means a belief or an interpretation by specialists 125
170	170	with experience in a specific area about the scientific evidence 126
171	171	pertaining to a particular service, intervention or therapy. 127
172	172	(18) "Facility" means an institution providing health care services or 128
173	173	a health care setting. "Facility" includes a hospital and other licensed 129
174	174	inpatient center, ambulatory surgical or treatment center, skilled 130
175	175	nursing center, residential treatment center, diagnostic, laboratory and 131
176	176	imaging center, and rehabilitation and other therapeutic health care 132
177	177	setting. 133
178	178	(19) "Final adverse determination" means an adverse determination 134 Raised Bill No. 341
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181	181
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184	184	(A) that has been upheld by the health carrier at the completion of its 135
185	185	internal grievance process, or (B) for which the internal grievance 136
186	186	process has been deemed exhausted. 137
187	187	(20) "Grievance" means a written complaint or, if the complaint 138
188	188	involves an urgent care request, an oral complaint, submitted by or on 139
189	189	behalf of a covered person regarding: 140
190	190	(A) The availability, delivery or quality of health care services, 141
191	191	including a complaint regarding an adverse determination made 142
192	192	pursuant to utilization review; 143
193	193	(B) Claims payment, handling or reimbursement for health care 144
194	194	services; or 145
195	195	(C) Any matter pertaining to the contractual relationship between a 146
196	196	covered person and a health carrier. 147
197	197	(21) (A) "Health benefit plan" means an insurance policy or contract, 148
198	198	certificate or agreement offered, delivered, issued for delivery, renewed, 149
199	199	amended or continued in this state to provide, deliver, arrange for, pay 150
200	200	for or reimburse any of the costs of health care services; 151
201	201	(B) "Health benefit plan" does not include: 152
202	202	(i) Coverage of the type specified in subdivisions (5) to (9), inclusive, 153
203	203	(14) and (15) of section 38a-469 or any combination thereof; 154
204	204	(ii) Coverage issued as a supplement to liability insurance; 155
205	205	(iii) Liability insurance, including general liability insurance and 156
206	206	automobile liability insurance; 157
207	207	(iv) Workers' compensation insurance; 158
208	208	(v) Automobile medical payment insurance; 159
209	209	(vi) Credit insurance; 160 Raised Bill No. 341
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215	215	(vii) Coverage for on-site medical clinics; 161
216	216	(viii) Other insurance coverage similar to the coverages specified in 162
217	217	subparagraphs (B)(ii) to (B)(vii), inclusive, of this subdivision that are 163
218	218	specified in regulations issued pursuant to the Health Insurance 164
219	219	Portability and Accountability Act of 1996, P.L. 104-191, as amended 165
220	220	from time to time, under which benefits for health care services are 166
221	221	secondary or incidental to other insurance benefits; 167
222	222	(ix) (I) Limited scope dental or vision benefits, (II) benefits for long-168
223	223	term care, nursing home care, home health care, community-based care 169
224	224	or any combination thereof, or (III) other similar, limited benefits 170
225	225	specified in regulations issued pursuant to the Health Insurance 171
226	226	Portability and Accountability Act of 1996, P.L. 104-191, as amended 172
227	227	from time to time, provided any benefits specified in subparagraphs 173
228	228	(B)(ix)(I) to (B)(ix)(III), inclusive, of this subdivision are provided under 174
229	229	a separate insurance policy, certificate or contract and are not otherwise 175
230	230	an integral part of a health benefit plan; or 176
231	231	(x) Coverage of the type specified in subdivisions (3) and (13) of 177
232	232	section 38a-469 or other fixed indemnity insurance if (I) they are 178
233	233	provided under a separate insurance policy, certificate or contract, (II) 179
234	234	there is no coordination between the provision of the benefits and any 180
235	235	exclusion of benefits under any group health plan maintained by the 181
236	236	same plan sponsor, and (III) the benefits are paid with respect to an 182
237	237	event without regard to whether benefits were also provided under any 183
238	238	group health plan maintained by the same plan sponsor. 184
239	239	(22) "Health care center" has the same meaning as provided in section 185
240	240	38a-175. 186
241	241	(23) "Health care professional" means a physician or other health care 187
242	242	practitioner licensed, accredited or certified to perform specified health 188
243	243	care services consistent with state law. 189
244	244	(24) "Health care services" has the same meaning as provided in 190
245	245	section 38a-478. 191 Raised Bill No. 341
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248	248
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251	251	(25) "Health carrier" means an entity subject to the insurance laws and 192
252	252	regulations of this state or subject to the jurisdiction of the 193
253	253	commissioner, that contracts or offers to contract to provide, deliver, 194
254	254	arrange for, pay for or reimburse any of the costs of health care services, 195
255	255	including a sickness and accident insurance company, a health care 196
256	256	center, a managed care organization, a hospital service corporation, a 197
257	257	medical service corporation or any other entity providing a plan of 198
258	258	health insurance, health benefits or health care services. 199
259	259	(26) "Health information" means information or data, whether oral or 200
260	260	recorded in any form or medium, and personal facts or information 201
261	261	about events or relationships that relate to (A) the past, present or future 202
262	262	physical, mental, or behavioral health or condition of a covered person 203
263	263	or a member of the covered person's family, (B) the provision of health 204
264	264	care services to a covered person, or (C) payment for the provision of 205
265	265	health care services to a covered person. 206
266	266	(27) "Independent review organization" means an entity that 207
267	267	conducts independent external reviews of adverse determinations and 208
268	268	final adverse determinations. Such review entities include, but are not 209
269	269	limited to, medical peer review organizations, independent utilization 210
270	270	review companies, provided such organizations or companies are not 211
271	271	related to or associated with any health carrier, and nationally 212
272	272	recognized health experts or institutions approved by the Insurance 213
273	273	Commissioner. 214
274	274	(28) "Medical or scientific evidence" means evidence found in the 215
275	275	following sources: 216
276	276	(A) Peer-reviewed scientific studies published in or accepted for 217
277	277	publication by medical journals that meet nationally recognized 218
278	278	requirements for scientific manuscripts and that submit most of their 219
279	279	published articles for review by experts who are not part of the editorial 220
280	280	staff; 221
281	281	(B) Peer-reviewed medical literature, including literature relating to 222
282	282	therapies reviewed and approved by a qualified institutional review 223 Raised Bill No. 341
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285	285
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288	288	board, biomedical compendia and other medical literature that meet the 224
289	289	criteria of the National Institutes of Health's Library of Medicine for 225
290	290	indexing in Index Medicus (Medline) or Elsevier Science for indexing in 226
291	291	Excerpta Medicus (EMBASE); 227
292	292	(C) Medical journals recognized by the Secretary of the United States 228
293	293	Department of Health and Human Services under Section 1861(t)(2) of 229
294	294	the Social Security Act; 230
295	295	(D) The following standard reference compendia: (i) The American 231
296	296	Hospital Formulary Service - Drug Information; (ii) Drug Facts and 232
297	297	Comparisons; (iii) The American Dental Association's Accepted Dental 233
298	298	Therapeutics; and (iv) The United States Pharmacopoeia - Drug 234
299	299	Information; 235
300	300	(E) Findings, studies or research conducted by or under the auspices 236
301	301	of federal government agencies and nationally recognized federal 237
302	302	research institutes, including: (i) The Agency for Healthcare Research 238
303	303	and Quality; (ii) the National Institutes of Health; (iii) the National 239
304	304	Cancer Institute; (iv) the National Academy of Sciences; (v) the Centers 240
305	305	for Medicare and Medicaid Services; (vi) the Food and Drug 241
306	306	Administration; and (vii) any national board recognized by the National 242
307	307	Institutes of Health for the purpose of evaluating the medical value of 243
308	308	health care services; or 244
309	309	(F) Any other findings, studies or research conducted by or under the 245
310	310	auspices of a source comparable to those listed in subparagraphs (E)(i) 246
311	311	to (E)(v), inclusive, of this subdivision. 247
312	312	(29) "Medical necessity" has the same meaning as provided in 248
313	313	sections 38a-482a and 38a-513c. 249
314	314	(30) "Participating provider" means a health care professional who, 250
315	315	under a contract with the health carrier, its contractor or subcontractor, 251
316	316	has agreed to provide health care services to covered persons, with an 252
317	317	expectation of receiving payment or reimbursement directly or 253
318	318	indirectly from the health carrier, other than coinsurance, copayments 254 Raised Bill No. 341
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324	324	or deductibles. 255
325	325	(31) "Person" has the same meaning as provided in section 38a-1. 256
326	326	(32) "Prospective review" means utilization review conducted prior 257
327	327	to an admission or the provision of a health care service or a course of 258
328	328	treatment, in accordance with a health carrier's requirement that such 259
329	329	service or treatment be approved, in whole or in part, prior to such 260
330	330	service's or treatment's provision. 261
331	331	(33) "Protected health information" means health information (A) that 262
332	332	identifies an individual who is the subject of the information, or (B) for 263
333	333	which there is a reasonable basis to believe that such information could 264
334	334	be used to identify such individual. 265
335	335	(34) "Randomized clinical trial" means a controlled, prospective 266
336	336	study of patients that have been randomized into an experimental 267
337	337	group and a control group at the beginning of the study, with only the 268
338	338	experimental group of patients receiving a specific intervention, and 269
339	339	that includes study of the groups for variables and anticipated outcomes 270
340	340	over time. 271
341	341	(35) "Rescission" means a cancellation or discontinuance of coverage 272
342	342	under a health benefit plan that has a retroactive effect. "Rescission" 273
343	343	does not include a cancellation or discontinuance of coverage under a 274
344	344	health benefit plan if (A) such cancellation or discontinuance has a 275
345	345	prospective effect only, or (B) such cancellation or discontinuance is 276
346	346	effective retroactively to the extent it is attributable to the covered 277
347	347	person's failure to timely pay required premiums or contributions 278
348	348	towards the cost of such coverage. 279
349	349	(36) "Retrospective review" means any review of a request for a 280
350	350	benefit that is not a prospective review or concurrent review. 281
351	351	"Retrospective review" does not include a review of a request that is 282
352	352	limited to the veracity of documentation or the accuracy of coding. 283
353	353	(37) "Stabilize" means, with respect to an emergency medical 284 Raised Bill No. 341
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356	356
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359	359	condition, that (A) no material deterioration of such condition is likely, 285
360	360	within reasonable medical probability, to result from or occur during 286
361	361	the transfer of the individual from a facility, or (B) with respect to a 287
362	362	pregnant woman, the woman has delivered, including the placenta. 288
363	363	(38) "Urgent care request" means a request for a health care service or 289
364	364	course of treatment (A) for which the time period for making a non-290
365	365	urgent care request determination (i) could seriously jeopardize the life 291
366	366	or health of the covered person or the ability of the covered person to 292
367	367	regain maximum function, or (ii) in the opinion of a health care 293
368	368	professional with knowledge of the covered person's medical condition, 294
369	369	would subject the covered person to severe pain that cannot be 295
370	370	adequately managed without the health care service or treatment being 296
371	371	requested, or (B) for a substance use disorder, as described in section 297
372	372	17a-458, or for a co-occurring mental disorder, or (C) for a mental 298
373	373	disorder requiring (i) inpatient services, (ii) partial hospitalization, as 299
374	374	defined in section 38a-496, (iii) residential treatment, or (iv) intensive 300
375	375	outpatient services necessary to keep a covered person from requiring 301
376	376	an inpatient setting. 302
377	377	(39) "Utilization review" means the use of a set of formal techniques 303
378	378	designed to monitor the use of, or evaluate the medical necessity, 304
379	379	appropriateness, efficacy or efficiency of, health care services, health 305
380	380	care procedures or health care settings. Such techniques may include the 306
381	381	monitoring of or evaluation of (A) health care services performed or 307
382	382	provided in an outpatient setting, (B) the formal process for 308
383	383	determining, prior to discharge from a facility, the coordination and 309
384	384	management of the care that a patient receives following discharge from 310
385	385	a facility, (C) opportunities or requirements to obtain a clinical 311
386	386	evaluation by a health care professional other than the one originally 312
387	387	making a recommendation for a proposed health care service, (D) 313
388	388	coordinated sets of activities conducted for individual patient 314
389	389	management of serious, complicated, protracted or other health 315
390	390	conditions, or (E) prospective review, concurrent review, retrospective 316
391	391	review or certification. 317 Raised Bill No. 341
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397	397	(40) "Utilization review company" means an entity that conducts 318
398	398	utilization review. 319
399	399	Sec. 3. Subsections (c) and (d) of section 38a-591b of the general 320
400	400	statutes are repealed and the following is substituted in lieu thereof 321
401	401	(Effective January 1, 2021): 322
402	402	(c) (1) A health carrier that requires utilization review of a benefit 323
403	403	request under a health benefit plan shall implement a utilization review 324
404	404	program and develop a written document that describes all utilization 325
405	405	review activities and procedures, whether or not delegated, for (A) the 326
406	406	filing of benefit requests, (B) the notification to covered persons of 327
407	407	utilization review and benefit determinations, and (C) the review of 328
408	408	adverse determinations and grievances in accordance with sections 38a-329
409	409	591e and 38a-591f. 330
410	410	(2) Such document shall describe the following: 331
411	411	(A) Procedures to evaluate the medical necessity, appropriateness, 332
412	412	health care setting, level of care or effectiveness of health care services; 333
413	413	(B) Data sources and clinical review criteria used in making 334
414	414	determinations; 335
415	415	(C) Procedures to ensure consistent application of clinical review 336
416	416	criteria and compatible determinations; 337
417	417	(D) Data collection processes and analytical methods used to assess 338
418	418	utilization of health care services; 339
419	419	(E) Provisions to ensure the confidentiality of clinical, proprietary 340
420	420	and protected health information; 341
421	421	(F) The health carrier's organizational mechanism, such as a 342
422	422	utilization review committee or quality assurance or other committee, 343
423	423	that periodically assesses the health carrier's utilization review program 344
424	424	and reports to the health carrier's governing body; [and] 345 Raised Bill No. 341
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430	430	(G) The health carrier's staff position that is responsible for the day-346
431	431	to-day management of the utilization review program; [.] and 347
432	432	(H) The right to submit a covered person's story pursuant to 348
433	433	subsection (b) or (c) of section 38a-591d, as amended by this act. 349
434	434	(d) Each health carrier shall: 350
435	435	(1) Include in the insurance policy, certificate of coverage or 351
436	436	handbook provided to covered persons a clear and comprehensive 352
437	437	description of: 353
438	438	(A) Its utilization review and benefit determination procedures; 354
439	439	(B) Its grievance procedures, including the grievance procedures for 355
440	440	requesting a review of an adverse determination; 356
441	441	(C) A description of the external review procedures set forth in 357
442	442	section 38a-591g, in a format prescribed by the commissioner and 358
443	443	including a statement that discloses that: 359
444	444	(i) A covered person may file a request for an external review of an 360
445	445	adverse determination or a final adverse determination with the 361
446	446	commissioner and that such review is available when the adverse 362
447	447	determination or the final adverse determination involves an issue of 363
448	448	medical necessity, appropriateness, health care setting, level of care or 364
449	449	effectiveness. Such disclosure shall include the contact information of 365
450	450	the commissioner; and 366
451	451	(ii) When filing a request for an external review of an adverse 367
452	452	determination or a final adverse determination, the covered person shall 368
453	453	be required to authorize the release of any medical records that may be 369
454	454	required to be reviewed for the purpose of making a decision on such 370
455	455	request; 371
456	456	(D) A statement of the rights and responsibilities of covered persons 372
457	457	with respect to each of the procedures under subparagraphs (A) to (C), 373
458	458	inclusive, of this subdivision. Such statement shall include a disclosure 374 Raised Bill No. 341
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464	464	that a covered person has the right to contact the commissioner's office 375
465	465	or the Office of Healthcare Advocate at any time for assistance and shall 376
466	466	include the contact information for said offices; 377
467	467	(E) A description of what constitutes a surprise bill, as defined in 378
468	468	subsection (a) of section 38a-477aa; 379
469	469	(F) The right to submit a covered person's story pursuant to 380
470	470	subsection (b) or (c) of section 38a-591d, as amended by this act; 381
471	471	(2) Inform its covered persons, at the time of initial enrollment and at 382
472	472	least annually thereafter, of its grievance procedures. This requirement 383
473	473	may be fulfilled by including such procedures in an enrollment 384
474	474	agreement or update to such agreement; 385
475	475	(3) Inform a covered person or the covered person's health care 386
476	476	professional, as applicable, at the time the covered person or the covered 387
477	477	person's health care professional requests a prospective or concurrent 388
478	478	review: (A) The network status under such covered person's health 389
479	479	benefit plan of the health care professional who will be providing the 390
480	480	health care service or course of treatment; (B) an estimate of the amount 391
481	481	the health carrier will reimburse such health care professional for such 392
482	482	service or treatment; and (C) how such amount compares to the usual, 393
483	483	customary and reasonable charge, as determined by the Centers for 394
484	484	Medicare and Medicaid Services, for such service or treatment; 395
485	485	(4) Inform a covered person and the covered person's health care 396
486	486	professional of the health carrier's grievance procedures whenever the 397
487	487	health carrier denies certification of a benefit requested by a covered 398
488	488	person's health care professional; 399
489	489	(5) Prominently post on its Internet web site the description required 400
490	490	under subparagraph (E) of subdivision (1) of this subsection; 401
491	491	(6) Include in materials intended for prospective covered persons a 402
492	492	summary of its utilization review and benefit determination 403
493	493	procedures; 404 Raised Bill No. 341
494	494
495	495
496	496
497	497	LCO No. 2033 15 of 18
498	498
499	499	(7) Print on its membership or identification cards a toll-free 405
500	500	telephone number for utilization review and benefit determinations; 406
501	501	(8) Maintain records of all benefit requests, claims and notices 407
502	502	associated with utilization review and benefit determinations made in 408
503	503	accordance with section 38a-591d, as amended by this act, for not less 409
504	504	than six years after such requests, claims and notices were made. Each 410
505	505	health carrier shall make such records available for examination by the 411
506	506	commissioner and appropriate federal oversight agencies upon request; 412
507	507	and 413
508	508	(9) Maintain records in accordance with section 38a-591h of all 414
509	509	grievances received. Each health carrier shall make such records 415
510	510	available for examination by covered persons, to the extent such records 416
511	511	are permitted to be disclosed by law, the commissioner and appropriate 417
512	512	federal oversight agencies upon request. 418
513	513	Sec. 4. Subsections (b) and (c) of section 38a-591d of the 2020 419
514	514	supplement to the general statutes are repealed and the following is 420
515	515	substituted in lieu thereof (Effective January 1, 2021): 421
516	516	(b) With respect to a nonurgent care request: 422
517	517	(1) (A) For a prospective or concurrent review request, [a] the health 423
518	518	carrier shall make a determination within a reasonable period of time 424
519	519	appropriate to the covered person's medical condition, but not later than 425
520	520	fifteen calendar days after the date the health carrier receives such 426
521	521	request, and shall notify the covered person and, if applicable, the 427
522	522	covered person's authorized representative of such determination, 428
523	523	whether or not the carrier certifies the provision of the benefit. 429
524	524	(B) If the review under subparagraph (A) of this subdivision is a 430
525	525	review of a grievance involving a concurrent review request, pursuant 431
526	526	to 45 CFR 147.136, as amended from time to time, the treatment shall be 432
527	527	continued without liability to the covered person until the covered 433
528	528	person has been notified of the review decision. 434 Raised Bill No. 341
529	529
530	530
531	531
532	532	LCO No. 2033 16 of 18
533	533
534	534	(2) For a retrospective review request, [a] the health carrier shall make 435
535	535	a determination within a reasonable period of time, but not later than 436
536	536	thirty calendar days after the date the health carrier receives such 437
537	537	request. 438
538	538	(3) The time periods specified in subdivisions (1) and (2) of this 439
539	539	subsection may be extended once by the health carrier for up to fifteen 440
540	540	calendar days, provided the health carrier: 441
541	541	(A) Determines that an extension is necessary due to circumstances 442
542	542	beyond the health carrier's control; and 443
543	543	(B) Notifies the covered person and, if applicable, the covered 444
544	544	person's authorized representative prior to the expiration of the initial 445
545	545	time period, of the circumstances requiring the extension of time and 446
546	546	the date by which the health carrier expects to make a determination. 447
547	547	(4) (A) If the extension pursuant to subdivision (3) of this subsection 448
548	548	is necessary due to the failure of the covered person or the covered 449
549	549	person's authorized representative to provide information necessary to 450
550	550	make a determination on the request, the health carrier shall: 451
551	551	(i) Specifically describe in the notice of extension the required 452
552	552	information necessary to complete the request; and 453
553	553	(ii) Provide the covered person and, if applicable, the covered 454
554	554	person's authorized representative with not less than forty-five calendar 455
555	555	days after the date of receipt of the notice to provide the specified 456
556	556	information. 457
557	557	(B) If the covered person or the covered person's authorized 458
558	558	representative fails to submit the specified information before the end 459
559	559	of the period of the extension, the health carrier may deny certification 460
560	560	of the benefit requested. 461
561	561	(5) The health carrier shall provide to the covered person or the 462
562	562	covered person's authorized representative, if applicable, the ability to 463
563	563	attach to or enclose the covered person's story with the request. 464 Raised Bill No. 341
564	564
565	565
566	566
567	567	LCO No. 2033 17 of 18
568	568
569	569	(c) With respect to an urgent care request: 465
570	570	(1) (A) Unless the covered person or the covered person's authorized 466
571	571	representative has failed to provide information necessary for the health 467
572	572	carrier to make a determination and except as specified under 468
573	573	subparagraph (B) of this subdivision, the health carrier shall make a 469
574	574	determination as soon as possible, taking into account the covered 470
575	575	person's medical condition, but not later than forty-eight hours after the 471
576	576	health carrier receives such request or seventy-two hours after such 472
577	577	health carrier receives such request if any portion of such forty-eight-473
578	578	hour period falls on a weekend, provided, if the urgent care request is a 474
579	579	concurrent review request to extend a course of treatment beyond the 475
580	580	initial period of time or the number of treatments, such request is made 476
581	581	at least twenty-four hours prior to the expiration of the prescribed 477
582	582	period of time or number of treatments. 478
583	583	(B) Unless the covered person or the covered person's authorized 479
584	584	representative has failed to provide information necessary for the health 480
585	585	carrier to make a determination, for an urgent care request specified 481
586	586	under subparagraph (B) or (C) of subdivision (38) of section 38a-591a, 482
587	587	as amended by this act, the health carrier shall make a determination as 483
588	588	soon as possible, taking into account the covered person's medical 484
589	589	condition, but not later than twenty-four hours after the health carrier 485
590	590	receives such request, provided, if the urgent care request is a 486
591	591	concurrent review request to extend a course of treatment beyond the 487
592	592	initial period of time or the number of treatments, such request is made 488
593	593	at least twenty-four hours prior to the expiration of the prescribed 489
594	594	period of time or number of treatments. 490
595	595	(2) (A) If the covered person or the covered person's authorized 491
596	596	representative has failed to provide information necessary for the health 492
597	597	carrier to make a determination, the health carrier shall notify the 493
598	598	covered person or the covered person's representative, as applicable, as 494
599	599	soon as possible, but not later than twenty-four hours after the health 495
600	600	carrier receives such request. 496 Raised Bill No. 341
601	601
602	602
603	603
604	604	LCO No. 2033 18 of 18
605	605
606	606	(B) The health carrier shall provide the covered person or the covered 497
607	607	person's authorized representative, as applicable, a reasonable period of 498
608	608	time to submit the specified information, taking into account the 499
609	609	covered person's medical condition, but not less than forty-eight hours 500
610	610	after notifying the covered person or the covered person's authorized 501
611	611	representative, as applicable. 502
612	612	(3) The health carrier shall notify the covered person and, if 503
613	613	applicable, the covered person's authorized representative of its 504
614	614	determination as soon as possible, but not later than forty-eight hours 505
615	615	after the earlier of (A) the date on which the covered person and the 506
616	616	covered person's authorized representative, as applicable, provides the 507
617	617	specified information to the health carrier, or (B) the date on which the 508
618	618	specified information was to have been submitted. 509
619	619	(4) The health carrier shall permit the covered person's treating health 510
620	620	care professional to attach or enclose the covered person's story with 511
621	621	such request. 512
622	622	This act shall take effect as follows and shall amend the following
623	623	sections:
624	624
625	625	Section 1 January 1, 2021 New section
626	626	Sec. 2 January 1, 2021 38a-591a
627	627	Sec. 3 January 1, 2021 38a-591b(c) and (d)
628	628	Sec. 4 January 1, 2021 38a-591d(b) and (c)
629	629
630	630	Statement of Purpose:
631	631	To: (1) Require health care professionals to notify covered persons and
632	632	their authorized representatives of their right to submit additional
633	633	information for consideration as part of a utilization review; and (2)
634	634	provide covered persons, authorized representatives and health care
635	635	professionals with a right to submit such additional information.
636	636	[Proposed deletions are enclosed in brackets. Proposed additions are indicated by underline, except
637	637	that when the entire text of a bill or resolution or a section of a bill or resolution is new, it is not
638	638	underlined.]
639	639