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OLR Bill Analysis
HB 5013
AN ACT CONCERNING MANDATED HEALTH INSURANCE
BENEFIT REVIEW.
SUMMARY
This bill modifies the Insurance Department’s mandated health
benefit review program. Beginning January 1, 2022, it also prohibits the
General Assembly from enacting legislation establishing a mandated
health benefit unless (1) the benefit has gone through the review
program and a legislative hearing or (2) two-thirds of the Insurance
and Real Estate Committee votes for it. (It is unclear whether this
requirement is enforceable based on the principle of legislative
entrenchment, under which one legislature generally cannot restrict a
future legislature’s ability to enact legislation.)
The bill authorizes the Insurance and Real Estate Committee, during
a regular legislative session and by a majority vote of its members, to
require the insurance commissioner to review and report on up to five
proposed mandated health benefits by the next January 1. Under
current law, the committee may request a review of any number of
existing or proposed benefits by August 1 of each year. By law,
unchanged by the bill, the commissioner may assess health carriers
(e.g., insurers and HMOs) for the costs of the health benefit review
program. Assessments are deposited in the Insurance Fund.
The bill requires the commissioner to submit the mandated health
benefit reports to the Insurance and Real Estate and Public Health
committees, which must hold a joint informational hearing on each
report. It requires him to attend each hearing to take members’
questions.
The bill also does the following:
1. narrows the definition of “mandated health benefit”; 2021HB-05013-R000328-BA.DOCX
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2. reduces the amount of information the commissioner’s reports
must include on each benefit;
3. allows, rather than requires, the commissioner to contract with
the UConn Center for Public Health and Health Policy to
conduct a review; and
4. allows him to contract with an actuarial accounting firm to
conduct a review.
EFFECTIVE DATE: July 1, 2021
MANDATED HEALTH BENE FIT REVIEW PROGRAM
Mandated Health Benefit Definition
The bill narrows the definition of “mandated health benefit.” Under
the bill, the term means proposed legislation that requires a health
carrier (e.g., insurer or HMO) offering health insurance policies or
benefit plans in the state to offer or provide coverage for (1) a
particular type of health care treatment or service or (2) medical
equipment, supplies, or drugs used in connection with a health
treatment or service.
Under current law, the term also includes the following, which the
bill eliminates:
1. an existing statutory obligation of the carrier to offer or provide
coverage;
2. proposed legislation to expand or repeal an existing coverage
obligation;
3. an existing obligation or proposed legislation allowing enrollees
to obtain treatment or services from a particular type of health
care provider; and
4. an existing obligation or proposed legislation to offer or provide
coverage for the screening, diagnosis, or treatment of a
particular disease or condition. 2021HB-05013-R000328-BA.DOCX
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Mandated Health Benefit Reports
Under the bill, the commissioner must report to the Insurance and
Real Estate and Public Health committees on the proposed mandated
health benefits by January 1 following a request. Current law requires
him to submit reports only to the Insurance and Real Estate
Committee.
The bill reduces the amount of information each report must
contain. Under current law, a report must review specified social and
financial impacts of mandating the benefit. The bill instead requires a
report to evaluate the specified quality and cost impacts of mandating
it.
Elements Required. As under existing law, each mandated health
benefit report must include the following elements:
1. the extent to which a significant portion of the population uses
the treatment, service, equipment, supplies, or drugs;
2. the extent to which the treatment, service, equipment, supplies,
or drugs are available under Medicare or through other public
programs;
3. the extent to which insurance policies already cover the
treatment, service, equipment, supplies, or drugs;
4. the effect of applying the benefit to the state employees’ health
benefits plan;
5. the extent to which credible scientific evidence published in
peer-reviewed medical literature determines the treatment,
service, equipment, supplies, or drugs are safe and effective;
6. the extent to which the benefit, over the next five years, may (a)
increase or decrease the cost of the treatment, service,
equipment, supplies, or drugs and (b) increase the appropriate
or inappropriate use of the benefit;
7. the extent to which the treatment, service, equipment, supplies, 2021HB-05013-R000328-BA.DOCX
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or drugs are more or less expensive than an existing one
determined to be equally safe and effective by credible scientific
evidence published in peer-reviewed medical literature;
8. the extent to which the benefit could be an alternative for more
or less expensive treatment, service, equipment, supplies, or
drugs;
9. the reasonably expected increase or decrease of a policyholder’s
insurance premiums and administrative expenses;
10. methods that will be implemented to manage the benefit’s use
and costs;
11. the effect on the (a) total cost of health care, including potential
savings to insurers and employers resulting from prevention or
early detection of disease or illness, and (b) cost of health care for
small employers and other employers; and
12. the effect on (a) cost-shifting between private and public payors
of health care coverage and (b) the overall cost of the state’s
health care delivery system.
Elements No Longer Required. The bill eliminates the following
elements from a mandated health benefit report:
1. if coverage of the benefit is not generally available, the extent to
which this results in (a) people being unable to obtain necessary
treatment and (b) unreasonable financial hardships on those
needing treatment;
2. the level of demand from the public and health care providers
for (a) the treatment, service, equipment, supplies, or drugs and
(b) insurance coverage for these;
3. the likelihood of meeting a consumer need based on other
states’ experiences;
4. relevant findings of state agencies or other appropriate public 2021HB-05013-R000328-BA.DOCX
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organizations relating to the benefit’s social impact;
5. alternatives to meeting the identified need, including other
treatments, methods, or procedures;
6. whether the benefit is (a) a medical or broader social need and
(b) consistent with the role of health insurance and managed
care concepts;
7. potential social implications regarding the direct or specific
creation of a comparable mandated benefit for similar diseases,
illnesses, or conditions;
8. the benefit’s impact on (a) the availability of other benefits
already offered and (b) employers shifting to self-insured plans;
and
9. the extent to which employers with self-insured plans offer the
benefit.
COMMITTEE ACTION
Insurance and Real Estate Committee
Joint Favorable
Yea 17 Nay 1 (03/22/2021)