Substitute House Bill No. 6389
Public Act No. 21-22
AN ACT CONCERNING EXPLANATIONS OF BENEFITS.
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 Section 38a-477d of the general statutes is repealed and the
following is substituted in lieu thereof (Effective January 1, 2023):
(a) Each insurer, health care center, hospital service corporation,
medical service corporation, fraternal benefit society or other entity that
delivers, issues for delivery, renews, amends or continues a health
insurance policy providing coverage of the type specified in
subdivisions (1), (2), (4), (11) and (12) of section 38a-469 in this state,
shall:
(1) Make available to consumers, in an easily readable, accessible and
understandable format: [, the]
(A) The following information for each such policy: [(A)]
(i) Any coverage exclusions; [(B) any]
(ii) Any restrictions on the use or quantity of a covered benefit,
including on prescription drugs or drugs administered in a physician's
office or a clinic; [(C) a] Substitute House Bill No. 6389
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(iii) A specific description of how prescription drugs are included or
excluded from any applicable deductible, including a description of
other out-of-pocket expenses that apply to such drugs; [(D) the]
(iv) The specific dollar amount of any copayment and the percentage
of any coinsurance imposed on each covered benefit, including each
covered prescription drug; and [(E) information]
(v) Information regarding any process available to consumers, and all
documents necessary, to seek coverage of a noncovered outpatient
prescription drug; and
(B) With respect to explanations of benefits issued pursuant to
subsections (d) to (i), inclusive, of this section, a statement disclosing
that each consumer who is a covered individual and legally capable of
consenting to the provision of covered benefits under such policy may
specify that such insurer, center, corporation, society or entity, and each
third-party administrator, as defined in section 38a-720, providing
services to such insurer, center, corporation, society or entity, shall:
(i) Not issue explanations of benefits concerning covered benefits
provided to such consumer; or
(ii) (I) Issue explanations of benefits concerning covered benefits
provided to such consumer solely to such consumer; and
(II) Use a method specified by such consumer to issue such
explanations of benefits solely to such consumer, and provide sufficient
space in the statement for such consumer to specify a mailing address
or an electronic mail address for such insurer, center, corporation,
society, entity or third-party administrator to use to contact such
consumer concerning covered benefits provided to such consumer.
(2) Make available to consumers a way to determine accurately: Substitute House Bill No. 6389
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(A) [whether] Whether a specific prescription drug is available under
such policy's drug formulary;
(B) [the] The coinsurance, copayment, deductible or other out-of-
pocket expense applicable to such drug;
(C) [whether] Whether such drug is covered when dispensed by a
physician or a clinic;
(D) [whether] Whether such drug requires prior authorization or the
use of step therapy;
(E) [whether] Whether specific types of health care specialists are in-
network; and
(F) [whether] Whether a specific health care provider or hospital is
in-network.
(b) (1) Each insurer, health care center, hospital service corporation,
medical service corporation, fraternal benefit society or other entity
shall make the information and statement required under subsection (a)
of this section available to consumers at the time of enrollment and shall
post such information and statement on its Internet web site.
(2) The Connecticut Health Insurance Exchange, established
pursuant to section 38a-1081, shall post links on its Internet web site to
such information and statement for each qualified health plan that is
offered or sold through the exchange.
(c) The Insurance Commissioner shall post links on the Insurance
Department's Internet web site to any on-line tools or calculators to help
consumers compare and evaluate health insurance policies and plans.
(d) Except as provided in subsection (g) of this section, each insurer,
health care center, hospital service corporation, medical service
corporation, fraternal benefit society or other entity that delivers, issues Substitute House Bill No. 6389
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for delivery, renews, amends or continues a health insurance policy
described in subsection (a) of this section, and each third-party
administrator, as defined in section 38a-720, providing services to such
an insurer, center, corporation, society or entity, shall:
(1) Issue explanations of benefits to consumers who are covered
individuals under the policy; and
(2) Permit each consumer who is a covered individual under the
policy and legally capable of consenting to the provision of covered
benefits to specify, in writing, that such insurer, center, corporation,
society, entity or third-party administrator issue explanations of
benefits concerning covered benefits provided to such consumer solely
to such consumer, and specify, in writing, which of the following
methods such insurer, center, corporation, society, entity or third-party
administrator shall use to issue such explanations of benefits solely to
such consumer:
(A) Mailing such explanations of benefits to such consumer's mailing
address or another mailing address specified by such consumer; or
(B) Making such explanations of benefits available to such consumer
by electronic means and notifying such consumer by electronic means,
including, but not limited to, electronic mail, when such insurer, center,
corporation, society, entity or third-party administrator makes each
such explanation of benefits available to such consumer by electronic
means, provided making such explanations of benefits available to such
consumer by electronic means and notifying such consumer by
electronic means complies with all applicable federal and state laws and
regulations concerning data security, including, but not limited to, 45
CFR Part 160, as amended from time to time, and 45 CFR Part 164,
Subparts A and C, as amended from time to time.
(e) Each method specified by a consumer, in writing, pursuant to Substitute House Bill No. 6389
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subdivision (2) of subsection (d) of this section shall be valid until the
consumer submits a written specification to the insurer, center,
corporation, society, entity or third-party administrator for a different
method. Such insurer, center, corporation, society, entity or third-party
administrator shall comply with a written specification under this
subsection or subdivision (2) of subsection (d) of this section, as
applicable, not later than three business days after such insurer, center,
corporation, society, entity or third-party administrator receives such
specification.
(f) Each insurer, center, corporation, society, entity or third-party
administrator that receives a written specification from a consumer
pursuant to subdivision (2) of subsection (d) of this section or subsection
(e) of this section, as applicable, shall provide the consumer who made
such specification with written confirmation that such insurer, center,
corporation, society, entity or third-party administrator received such
specification, and advise such consumer, in writing, regarding the status
of such specification if such consumer contacts such insurer, center,
corporation, society, entity or third-party administrator, in writing,
regarding such specification.
(g) Each consumer who is a covered individual under a policy
described in subsection (a) of this section and is legally capable of
consenting to the provision of covered benefits may specify, in writing,
that the insurer, center, corporation, society or entity that delivered,
issued for delivery, renewed, amended or continued the policy, or a
third-party administrator providing services to such insurer, center,
corporation, society or entity, not issue explanations of benefits
pursuant to subsections (d) to (f), inclusive, of this section if such
explanations of benefits concern covered benefits that were provided to
such consumer. Such insurer, center, corporation, society, entity or
third-party administrator shall not require such consumer to provide
any explanation regarding the basis for such consumer's specification, Substitute House Bill No. 6389
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unless such explanation is required by applicable law or pursuant to an
order issued by a court of competent jurisdiction.
(h) Each insurer, center, corporation, society or entity that delivers,
issues for delivery, renews, amends or continues a policy described in
subsection (a) of this section, and each third-party administrator
providing services to such insurer, center, corporation, society or entity,
shall disclose to each consumer who is a covered individual under the
policy such consumer's ability to submit specifications pursuant to
subsections (d) to (g), inclusive, of this section. Such disclosure shall be
in plain language and displayed or printed, as applicable, clearly and
conspicuously in all evidence of coverage documents, privacy
communications, explanations of benefits and Internet web sites that are
maintained by such insurer, center, corporation, society, entity or third-
party administrator and accessible to consumers in this state.
(i) No insurer, center, corporation, society or entity that is subject to
subsections (d) to (h), inclusive, of this section shall require a consumer
or policyholder to waive any right to limit disclosure under subsections
(d) to (h), inclusive, of this section as a precondition to delivering,
issuing for delivery, renewing, amending or continuing a policy
described in subsection (a) of this section to the consumer or
policyholder. Nothing in this subsection or subsections (d) to (h),
inclusive, of this section shall be construed to limit a consumer's or
policyholder's ability to request review of an adverse determination.