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General Assembly Raised Bill No. 6389
January Session, 2021
LCO No. 2692
Referred to Committee on INSURANCE AND REAL ESTATE
Introduced by:
(INS)
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 Section 38a-477d of the general statutes is repealed and the 1
following is substituted in lieu thereof (Effective January 1, 2023): 2
(a) Each insurer, health care center, hospital service corporation, 3
medical service corporation, fraternal benefit society or other entity that 4
delivers, issues for delivery, renews, amends or continues a health 5
insurance policy providing coverage of the type specified in 6
subdivisions (1), (2), (4), (11) and (12) of section 38a-469 in this state, 7
shall: 8
(1) Make available to consumers, in an easily readable, accessible and 9
understandable format: [, the] 10
(A) The following information for each such policy: 11
[(A)] (i) Any coverage exclusions; 12
[(B) any] (ii) Any restrictions on the use or quantity of a covered 13 Raised Bill No. 6389
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benefit, including on prescription drugs or drugs administered in a 14
physician's office or a clinic; 15
[(C) a] (iii) A specific description of how prescription drugs are 16
included or excluded from any applicable deductible, including a 17
description of other out-of-pocket expenses that apply to such drugs; 18
[(D) the] (iv) The specific dollar amount of any copayment and the 19
percentage of any coinsurance imposed on each covered benefit, 20
including each covered prescription drug; and 21
[(E) information] (v) Information regarding any process available to 22
consumers, and all documents necessary, to seek coverage of a 23
noncovered outpatient prescription drug; and 24
(B) With respect to explanations of benefits issued pursuant to 25
subsection (d) of this section, a statement disclosing that each consumer 26
who is a covered individual and legally capable of consenting to the 27
provision of covered benefits under such policy may specify that such 28
insurer, center, corporation, society or entity, and each third-party 29
administrator, as defined in section 38a-720, providing services to such 30
insurer, center, corporation, society or entity, shall: 31
(i) Not issue explanations of benefits concerning covered benefits 32
provided to such consumer; or 33
(ii) (I) Issue explanations of benefits concerning covered benefits 34
provided to such consumer solely to such consumer; and 35
(II) Use a method specified by such consumer to issue such 36
explanations of benefits solely to such consumer, and provide sufficient 37
space in the statement for such consumer to specify a mailing address 38
or an electronic mail address for such insurer, center, corporation, 39
society, entity or third-party administrator to use to contact such 40
consumer concerning covered benefits provided to such consumer. 41
(2) Make available to consumers a way to determine accurately: 42 Raised Bill No. 6389
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(A) [whether] Whether a specific prescription drug is available under 43
such policy's drug formulary; 44
(B) [the] The coinsurance, copayment, deductible or other out-of-45
pocket expense applicable to such drug; 46
(C) [whether] Whether such drug is covered when dispensed by a 47
physician or a clinic; 48
(D) [whether] Whether such drug requires prior authorization or the 49
use of step therapy; 50
(E) [whether] Whether specific types of health care specialists are in-51
network; and 52
(F) [whether] Whether a specific health care provider or hospital is 53
in-network. 54
(b) (1) Each insurer, health care center, hospital service corporation, 55
medical service corporation, fraternal benefit society or other entity 56
shall make the information and statement required under subsection (a) 57
of this section available to consumers at the time of enrollment and shall 58
post such information and statement on its Internet web site. 59
(2) The Connecticut Health Insurance Exchange, established 60
pursuant to section 38a-1081, shall post links on its Internet web site to 61
such information and statement for each qualified health plan that is 62
offered or sold through the exchange. 63
(c) The Insurance Commissioner shall post links on the Insurance 64
Department's Internet web site to any on-line tools or calculators to help 65
consumers compare and evaluate health insurance policies and plans. 66
(d) (1) Except as provided in subdivision (2) of this subsection, each 67
insurer, health care center, hospital service corporation, medical service 68
corporation, fraternal benefit society or other entity that delivers, issues 69
for delivery, renews, amends or continues a health insurance policy 70
described in subsection (a) of this section, and each third-party 71 Raised Bill No. 6389
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administrator, as defined in section 38a-720, providing services to such 72
an insurer, center, corporation, society or entity, shall: 73
(A) Issue explanations of benefits to 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, in writing, that such insurer, center, corporation, 78
society, entity or third-party administrator issue explanations of 79
benefits concerning covered benefits provided to such consumer solely 80
to such consumer, and specify, in writing, which of the following 81
methods such insurer, center, corporation, society, entity or third-party 82
administrator shall use to issue such explanations of benefits solely to 83
such consumer: 84
(I) Mailing such explanations of benefits to such consumer's mailing 85
address or another mailing address specified by such consumer; 86
(II) Sending such explanations of benefits to such consumer by 87
electronic means, including, but not limited to, electronic mail; or 88
(III) Making such explanations of benefits available to such consumer 89
by electronic means, provided making such explanations of benefits 90
available solely to such consumer by electronic means complies with all 91
applicable federal and state laws and regulations concerning data 92
security, including, but not limited to, 45 CFR Part 160, as amended from 93
time to time, and 45 CFR Part 164, Subparts A and C, as amended from 94
time to time. 95
(ii) Each method specified by a consumer, in writing, pursuant to 96
subparagraph (B)(i) of this subdivision shall be valid until the consumer 97
submits a written specification to the insurer, center, corporation, 98
society, entity or third-party administrator for a different method. Such 99
insurer, center, corporation, society, entity or third-party administrator 100
shall comply with a written specification under this clause or 101
subparagraph (B)(i) of this subdivision, as applicable, not later than 102 Raised Bill No. 6389
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three business days after such insurer, center, corporation, society, 103
entity or third-party administrator receives such specification. 104
(iii) Each insurer, center, corporation, society, entity or third-party 105
administrator that receives a written specification from a consumer 106
pursuant to subparagraph (B)(i) or (B)(ii) of this subdivision, as 107
applicable, shall provide the consumer who made such specification 108
with written confirmation that such insurer, center, corporation, society, 109
entity or third-party administrator received such specification, and 110
advise such consumer, in writing, regarding the status of such 111
specification if such consumer contacts such insurer, center, 112
corporation, society, entity or third-party administrator, in writing, 113
regarding such specification. 114
(2) Each consumer who is a covered individual under a policy 115
described in subsection (a) of this section and is legally capable of 116
consenting to the provision of covered benefits may specify, in writing, 117
that the insurer, center, corporation, society or entity that delivered, 118
issued for delivery, renewed, amended or continued the policy, or a 119
third-party administrator providing services to such insurer, center, 120
corporation, society or entity, not issue explanations of benefits 121
pursuant to subdivision (1) of this subsection if such explanations of 122
benefits concern covered benefits that were provided to such consumer. 123
Such insurer, center, corporation, society, entity or third-party 124
administrator shall not require such consumer to provide any 125
explanation regarding the basis for such consumer's specification, 126
unless such explanation is required by applicable law or pursuant to an 127
order issued by a court of competent jurisdiction. 128
(3) Each insurer, center, corporation, society or entity that delivers, 129
issues for delivery, renews, amends or continues a policy described in 130
subsection (a) of this section, and each third-party administrator 131
providing services to such insurer, center, corporation, society or entity, 132
shall disclose to each consumer who is a covered individual under the 133
policy such consumer's ability to submit specifications pursuant to 134
subdivisions (1) and (2) of this subsection. Such disclosure shall be in 135 Raised Bill No. 6389
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plain language and displayed or printed, as applicable, clearly and 136
conspicuously in all evidence of coverage documents, privacy 137
communications, explanations of benefits and Internet web sites that are 138
maintained by such insurer, center, corporation, society, entity or third-139
party administrator and accessible to consumers in this state. 140
(4) No insurer, center, corporation, society or entity that is subject to 141
this subsection shall require a consumer or policyholder to waive any 142
right to limit disclosure under this subsection as a precondition to 143
delivering, issuing for delivery, renewing, amending or continuing a 144
policy described in subsection (a) of this section to the consumer or 145
policyholder. Nothing in this subsection shall be construed to limit a 146
consumer's or policyholder's ability to request review of an adverse 147
determination. 148
This act shall take effect as follows and shall amend the following
sections:
Section 1 January 1, 2023 38a-477d
Statement of Purpose:
To: (1) Require health insurers that deliver, issue for delivery, renew,
amend or continue certain health insurance policies in this state to (A)
issue explanations of benefits to consumers in certain circumstances,
and (B) disclose information concerning explanations of benefits to
consumers; and (2) 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.]