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General Assembly Substitute Bill No. 6389
January Session, 2021
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 Section 38a-477d of the general statutes is repealed and the 1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: [(A)] 11
(i) Any coverage exclusions; [(B) any] 12
(ii) Any restrictions on the use or quantity of a covered benefit, 13
including on prescription drugs or drugs administered in a physician's 14
office or a clinic; [(C) a] 15
(iii) A specific description of how prescription drugs are included or 16
excluded from any applicable deductible, including a description of 17 Substitute Bill No. 6389
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other out-of-pocket expenses that apply to such drugs; [(D) the] 18
(iv) The specific dollar amount of any copayment and the percentage 19
of any coinsurance imposed on each covered benefit, including each 20
covered prescription drug; and [(E) information] 21
(v) Information regarding any process available to consumers, and all 22
documents necessary, to seek coverage of a noncovered outpatient 23
prescription drug; and 24
(B) With respect to explanations of benefits issued pursuant to 25
subsections (d) to (i), inclusive, of this section, a statement disclosing 26
that each consumer who is a covered individual and legally capable of 27
consenting to the provision of covered benefits under such policy may 28
specify that such insurer, center, corporation, society or entity, and each 29
third-party administrator, as defined in section 38a-720, providing 30
services to such 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
(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 Substitute Bill No. 6389
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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) Except as provided in subsection (g) of this section, each insurer, 67
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
administrator, as defined in section 38a-720, providing services to such 72
an insurer, center, corporation, society or entity, shall: 73 Substitute Bill No. 6389
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(1) Issue explanations of benefits to consumers who are covered 74
individuals under the policy; and 75
(2) 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
(A) Mailing such explanations of benefits to such consumer's mailing 85
address or another mailing address specified by such consumer; 86
(B) Sending such explanations of benefits to such consumer by 87
electronic means, including, but not limited to, electronic mail; or 88
(C) 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
(e) Each method specified by a consumer, in writing, pursuant to 96
subdivision (2) of subsection (d) of this section shall be valid until the 97
consumer submits a written specification to the insurer, center, 98
corporation, society, entity or third-party administrator for a different 99
method. Such insurer, center, corporation, society, entity or third-party 100
administrator shall comply with a written specification under this 101
subsection or subdivision (2) of subsection (d) of this section, as 102
applicable, not later than three business days after such insurer, center, 103
corporation, society, entity or third-party administrator receives such 104 Substitute Bill No. 6389
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specification. 105
(f) Each insurer, center, corporation, society, entity or third-party 106
administrator that receives a written specification from a consumer 107
pursuant to subdivision (2) of subsection (d) of this section or subsection 108
(e) of this section, as applicable, shall provide the consumer who made 109
such specification with written confirmation that such insurer, center, 110
corporation, society, entity or third-party administrator received such 111
specification, and advise such consumer, in writing, regarding the status 112
of such specification if such consumer contacts such insurer, center, 113
corporation, society, entity or third-party administrator, in writing, 114
regarding such specification. 115
(g) Each consumer who is a covered individual under a policy 116
described in subsection (a) of this section and is legally capable of 117
consenting to the provision of covered benefits may specify, in writing, 118
that the insurer, center, corporation, society or entity that delivered, 119
issued for delivery, renewed, amended or continued the policy, or a 120
third-party administrator providing services to such insurer, center, 121
corporation, society or entity, not issue explanations of benefits 122
pursuant to subsections (d) to (f), inclusive, of this section if such 123
explanations of benefits concern covered benefits that were provided to 124
such consumer. Such insurer, center, corporation, society, entity or 125
third-party administrator shall not require such consumer to provide 126
any explanation regarding the basis for such consumer's specification, 127
unless such explanation is required by applicable law or pursuant to an 128
order issued by a court of competent jurisdiction. 129
(h) Each insurer, center, corporation, society or entity that delivers, 130
issues for delivery, renews, amends or continues a policy described in 131
subsection (a) of this section, and each third-party administrator 132
providing services to such insurer, center, corporation, society or entity, 133
shall disclose to each consumer who is a covered individual under the 134
policy such consumer's ability to submit specifications pursuant to 135
subsections (d) to (g), inclusive, of this section. Such disclosure shall be 136
in plain language and displayed or printed, as applicable, clearly and 137 Substitute Bill No. 6389
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conspicuously in all evidence of coverage documents, privacy 138
communications, explanations of benefits and Internet web sites that are 139
maintained by such insurer, center, corporation, society, entity or third-140
party administrator and accessible to consumers in this state. 141
(i) No insurer, center, corporation, society or entity that is subject to 142
subsections (d) to (h), inclusive, of this section shall require a consumer 143
or policyholder to waive any right to limit disclosure under subsections 144
(d) to (h), inclusive, of this section as a precondition to delivering, 145
issuing for delivery, renewing, amending or continuing a policy 146
described in subsection (a) of this section to the consumer or 147
policyholder. Nothing in this subsection or subsections (d) to (h), 148
inclusive, of this section shall be construed to limit a consumer's or 149
policyholder's ability to request review of an adverse determination. 150
This act shall take effect as follows and shall amend the following
sections:
Section 1 January 1, 2023 38a-477d
Statement of Legislative Commissioners:
In Subsec. (a)(1)(B), "subsections (d) to (i), inclusive," was substituted for
"subsection (d)" for internal consistency; in Subsec. (d), Subsec. (d)(1)
was redesignated Subsec. (d), Subsec. (d)(1)(A) was redesignated
Subsec. (d)(1), Subsec. (d)(1)(B)(i) was redesignated Subsec. (d)(2),
Subsec. (d)(1)(B)(i)(I) was redesignated Subsec. (d)(2)(A), Subsec.
(d)(1)(B)(i)(II) was redesignated Subsec. (d)(2)(B), Subsec.
(d)(1)(B)(i)(III) was redesignated Subsec. (d)(2)(C), Subsec. (d)(1)(B)(ii)
was redesignated Subsec. (e), Subsec. (d)(1)(B)(iii) was redesignated
Subsec. (f), Subsec. (d)(2) was redesignated Subsec. (g), Subsec. (d)(3)
was redesignated Subsec. (h) and Subsec. (d)(4) was redesignated
Subsec. (i) for consistency with standard drafting conventions; in
Subsec. (d), "subsection (g) of this section" was substituted for
"subdivision (2) of this subsection" for internal consistency; in Subsec.
(e), "subdivision (2) of subsection (d) of this section" was substituted for
"subparagraph (B)(i) of this subdivision", and "this subsection or
subdivision (2) of subsection (d) of this section" was substituted for "this
clause or subparagraph (B)(i) of this subdivision", for internal
consistency; in Subsec. (f), "subdivision (2) of subsection (d) of this Substitute Bill No. 6389
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section or subsection (e) of this section" was substituted for
"subparagraph (B)(i) or (B)(ii) of this subdivision" for internal
consistency; in Subsec. (g), "subsections (d) to (f), inclusive, of this
section" was substituted for "subdivision (1) of this subsection" for
internal consistency; in Subsec. (h), "subsections (d) to (g), inclusive, of
this section" was substituted for "subdivisions (1) and (2) of this
subsection" for internal consistency; and in Subsec. (i), "subsections (d)
to (h), inclusive, of this section" was substituted for "this subsection" in
two instances, and "or subsections (d) to (h), inclusive, of this section"
was added, for internal consistency.
INS Joint Favorable Subst. -LCO