Connecticut 2021 Regular Session

Connecticut House Bill HB06389 Compare Versions

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Version 2 (New)

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4		-	Substitute House Bill No. 6389
	7	+	General Assembly Substitute Bill No. 6389
	8	+	January Session, 2021
5	9
6		-	Public Act No. 21-22
7	10
8	11
9	12		AN ACT CONCERNING EX PLANATIONS OF BENEFI TS.
10	13		Be it enacted by the Senate and House of Representatives in General
11	14		Assembly convened:
12	15
13		-	Section 1. Section 38a-477d of the general statutes is repealed and the
14		-	following is substituted in lieu thereof (Effective January 1, 2023):
15		-	(a) Each insurer, health care center, hospital service corporation,
16		-	medical service corporation, fraternal benefit society or other entity that
17		-	delivers, issues for delivery, renews, amends or continues a health
18		-	insurance policy providing coverage of the type specified in
19		-	subdivisions (1), (2), (4), (11) and (12) of section 38a-469 in this state,
20		-	shall:
21		-	(1) Make available to consumers, in an easily readable, accessible and
22		-	understandable format: [, the]
23		-	(A) The following information for each such policy: [(A)]
24		-	(i) Any coverage exclusions; [(B) any]
25		-	(ii) Any restrictions on the use or quantity of a covered benefit,
26		-	including on prescription drugs or drugs administered in a physician's
27		-	office or a clinic; [(C) a] Substitute House Bill No. 6389
	16	+	Section 1. Section 38a-477d of the general statutes is repealed and the 1
	17	+	following is substituted in lieu thereof (Effective January 1, 2023): 2
	18	+	(a) Each insurer, health care center, hospital service corporation, 3
	19	+	medical service corporation, fraternal benefit society or other entity that 4
	20	+	delivers, issues for delivery, renews, amends or continues a health 5
	21	+	insurance policy providing coverage of the type specified in 6
	22	+	subdivisions (1), (2), (4), (11) and (12) of section 38a-469 in this state, 7
	23	+	shall: 8
	24	+	(1) Make available to consumers, in an easily readable, accessible and 9
	25	+	understandable format: [, the] 10
	26	+	(A) The following information for each such policy: [(A)] 11
	27	+	(i) Any coverage exclusions; [(B) any] 12
	28	+	(ii) Any restrictions on the use or quantity of a covered benefit, 13
	29	+	including on prescription drugs or drugs administered in a physician's 14
	30	+	office or a clinic; [(C) a] 15
	31	+	(iii) A specific description of how prescription drugs are included or 16
	32	+	excluded from any applicable deductible, including a description of 17 Substitute Bill No. 6389
28	33
29		-	Public Act No. 21-22 2 of 6
30	34
31		-	(iii) A specific description of how prescription drugs are included or
32		-	excluded from any applicable deductible, including a description of
33		-	other out-of-pocket expenses that apply to such drugs; [(D) the]
34		-	(iv) The specific dollar amount of any copayment and the percentage
35		-	of any coinsurance imposed on each covered benefit, including each
36		-	covered prescription drug; and [(E) information]
37		-	(v) Information regarding any process available to consumers, and all
38		-	documents necessary, to seek coverage of a noncovered outpatient
39		-	prescription drug; and
40		-	(B) With respect to explanations of benefits issued pursuant to
41		-	subsections (d) to (i), inclusive, of this section, a statement disclosing
42		-	that each consumer who is a covered individual and legally capable of
43		-	consenting to the provision of covered benefits under such policy may
44		-	specify that such insurer, center, corporation, society or entity, and each
45		-	third-party administrator, as defined in section 38a-720, providing
46		-	services to such insurer, center, corporation, society or entity, shall:
47		-	(i) Not issue explanations of benefits concerning covered benefits
48		-	provided to such consumer; or
49		-	(ii) (I) Issue explanations of benefits concerning covered benefits
50		-	provided to such consumer solely to such consumer; and
51		-	(II) Use a method specified by such consumer to issue such
52		-	explanations of benefits solely to such consumer, and provide sufficient
53		-	space in the statement for such consumer to specify a mailing address
54		-	or an electronic mail address for such insurer, center, corporation,
55		-	society, entity or third-party administrator to use to contact such
56		-	consumer concerning covered benefits provided to such consumer.
57		-	(2) Make available to consumers a way to determine accurately: Substitute House Bill No. 6389
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	39	+	other out-of-pocket expenses that apply to such drugs; [(D) the] 18
	40	+	(iv) The specific dollar amount of any copayment and the percentage 19
	41	+	of any coinsurance imposed on each covered benefit, including each 20
	42	+	covered prescription drug; and [(E) information] 21
	43	+	(v) Information regarding any process available to consumers, and all 22
	44	+	documents necessary, to seek coverage of a noncovered outpatient 23
	45	+	prescription drug; and 24
	46	+	(B) With respect to explanations of benefits issued pursuant to 25
	47	+	subsections (d) to (i), inclusive, of this section, a statement disclosing 26
	48	+	that each consumer who is a covered individual and legally capable of 27
	49	+	consenting to the provision of covered benefits under such policy may 28
	50	+	specify that such insurer, center, corporation, society or entity, and each 29
	51	+	third-party administrator, as defined in section 38a-720, providing 30
	52	+	services to such insurer, center, corporation, society or entity, shall: 31
	53	+	(i) Not issue explanations of benefits concerning covered benefits 32
	54	+	provided to such consumer; or 33
	55	+	(ii) (I) Issue explanations of benefits concerning covered benefits 34
	56	+	provided to such consumer solely to such consumer; and 35
	57	+	(II) Use a method specified by such consumer to issue such 36
	58	+	explanations of benefits solely to such consumer, and provide sufficient 37
	59	+	space in the statement for such consumer to specify a mailing address 38
	60	+	or an electronic mail address for such insurer, center, corporation, 39
	61	+	society, entity or third-party administrator to use to contact such 40
	62	+	consumer concerning covered benefits provided to such consumer. 41
	63	+	(2) Make available to consumers a way to determine accurately: 42
	64	+	(A) [whether] Whether a specific prescription drug is available under 43
	65	+	such policy's drug formulary; 44
	66	+	(B) [the] The coinsurance, copayment, deductible or other out-of-45 Substitute Bill No. 6389
60	67
61		-	(A) [whether] Whether a specific prescription drug is available under
62		-	such policy's drug formulary;
63		-	(B) [the] The coinsurance, copayment, deductible or other out-of-
64		-	pocket expense applicable to such drug;
65		-	(C) [whether] Whether such drug is covered when dispensed by a
66		-	physician or a clinic;
67		-	(D) [whether] Whether such drug requires prior authorization or the
68		-	use of step therapy;
69		-	(E) [whether] Whether specific types of health care specialists are in-
70		-	network; and
71		-	(F) [whether] Whether a specific health care provider or hospital is
72		-	in-network.
73		-	(b) (1) Each insurer, health care center, hospital service corporation,
74		-	medical service corporation, fraternal benefit society or other entity
75		-	shall make the information and statement required under subsection (a)
76		-	of this section available to consumers at the time of enrollment and shall
77		-	post such information and statement on its Internet web site.
78		-	(2) The Connecticut Health Insurance Exchange, established
79		-	pursuant to section 38a-1081, shall post links on its Internet web site to
80		-	such information and statement for each qualified health plan that is
81		-	offered or sold through the exchange.
82		-	(c) The Insurance Commissioner shall post links on the Insurance
83		-	Department's Internet web site to any on-line tools or calculators to help
84		-	consumers compare and evaluate health insurance policies and plans.
85		-	(d) Except as provided in subsection (g) of this section, each insurer,
86		-	health care center, hospital service corporation, medical service
87		-	corporation, fraternal benefit society or other entity that delivers, issues Substitute House Bill No. 6389
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91		-	for delivery, renews, amends or continues a health insurance policy
92		-	described in subsection (a) of this section, and each third-party
93		-	administrator, as defined in section 38a-720, providing services to such
94		-	an insurer, center, corporation, society or entity, shall:
95		-	(1) Issue explanations of benefits to consumers who are covered
96		-	individuals under the policy; and
97		-	(2) Permit each consumer who is a covered individual under the
98		-	policy and legally capable of consenting to the provision of covered
99		-	benefits to specify, in writing, that such insurer, center, corporation,
100		-	society, entity or third-party administrator issue explanations of
101		-	benefits concerning covered benefits provided to such consumer solely
102		-	to such consumer, and specify, in writing, which of the following
103		-	methods such insurer, center, corporation, society, entity or third-party
104		-	administrator shall use to issue such explanations of benefits solely to
105		-	such consumer:
106		-	(A) Mailing such explanations of benefits to such consumer's mailing
107		-	address or another mailing address specified by such consumer; or
108		-	(B) Making such explanations of benefits available to such consumer
109		-	by electronic means and notifying such consumer by electronic means,
110		-	including, but not limited to, electronic mail, when such insurer, center,
111		-	corporation, society, entity or third-party administrator makes each
112		-	such explanation of benefits available to such consumer by electronic
113		-	means, provided making such explanations of benefits available to such
114		-	consumer by electronic means and notifying such consumer by
115		-	electronic means complies with all applicable federal and state laws and
116		-	regulations concerning data security, including, but not limited to, 45
117		-	CFR Part 160, as amended from time to time, and 45 CFR Part 164,
118		-	Subparts A and C, as amended from time to time.
119		-	(e) Each method specified by a consumer, in writing, pursuant to Substitute House Bill No. 6389
	73	+	pocket expense applicable to such drug; 46
	74	+	(C) [whether] Whether such drug is covered when dispensed by a 47
	75	+	physician or a clinic; 48
	76	+	(D) [whether] Whether such drug requires prior authorization or the 49
	77	+	use of step therapy; 50
	78	+	(E) [whether] Whether specific types of health care specialists are in-51
	79	+	network; and 52
	80	+	(F) [whether] Whether a specific health care provider or hospital is 53
	81	+	in-network. 54
	82	+	(b) (1) Each insurer, health care center, hospital service corporation, 55
	83	+	medical service corporation, fraternal benefit society or other entity 56
	84	+	shall make the information and statement required under subsection (a) 57
	85	+	of this section available to consumers at the time of enrollment and shall 58
	86	+	post such information and statement on its Internet web site. 59
	87	+	(2) The Connecticut Health Insurance Exchange, established 60
	88	+	pursuant to section 38a-1081, shall post links on its Internet web site to 61
	89	+	such information and statement for each qualified health plan that is 62
	90	+	offered or sold through the exchange. 63
	91	+	(c) The Insurance Commissioner shall post links on the Insurance 64
	92	+	Department's Internet web site to any on-line tools or calculators to help 65
	93	+	consumers compare and evaluate health insurance policies and plans. 66
	94	+	(d) Except as provided in subsection (g) of this section, each insurer, 67
	95	+	health care center, hospital service corporation, medical service 68
	96	+	corporation, fraternal benefit society or other entity that delivers, issues 69
	97	+	for delivery, renews, amends or continues a health insurance policy 70
	98	+	described in subsection (a) of this section, and each third-party 71
	99	+	administrator, as defined in section 38a-720, providing services to such 72
	100	+	an insurer, center, corporation, society or entity, shall: 73 Substitute Bill No. 6389
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122	102
123		-	subdivision (2) of subsection (d) of this section shall be valid until the
124		-	consumer submits a written specification to the insurer, center,
125		-	corporation, society, entity or third-party administrator for a different
126		-	method. Such insurer, center, corporation, society, entity or third-party
127		-	administrator shall comply with a written specification under this
128		-	subsection or subdivision (2) of subsection (d) of this section, as
129		-	applicable, not later than three business days after such insurer, center,
130		-	corporation, society, entity or third-party administrator receives such
131		-	specification.
132		-	(f) Each insurer, center, corporation, society, entity or third-party
133		-	administrator that receives a written specification from a consumer
134		-	pursuant to subdivision (2) of subsection (d) of this section or subsection
135		-	(e) of this section, as applicable, shall provide the consumer who made
136		-	such specification with written confirmation that such insurer, center,
137		-	corporation, society, entity or third-party administrator received such
138		-	specification, and advise such consumer, in writing, regarding the status
139		-	of such specification if such consumer contacts such insurer, center,
140		-	corporation, society, entity or third-party administrator, in writing,
141		-	regarding such specification.
142		-	(g) Each consumer who is a covered individual under a policy
143		-	described in subsection (a) of this section and is legally capable of
144		-	consenting to the provision of covered benefits may specify, in writing,
145		-	that the insurer, center, corporation, society or entity that delivered,
146		-	issued for delivery, renewed, amended or continued the policy, or a
147		-	third-party administrator providing services to such insurer, center,
148		-	corporation, society or entity, not issue explanations of benefits
149		-	pursuant to subsections (d) to (f), inclusive, of this section if such
150		-	explanations of benefits concern covered benefits that were provided to
151		-	such consumer. Such insurer, center, corporation, society, entity or
152		-	third-party administrator shall not require such consumer to provide
153		-	any explanation regarding the basis for such consumer's specification, Substitute House Bill No. 6389
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	107	+	(1) Issue explanations of benefits to consumers who are covered 74
	108	+	individuals under the policy; and 75
	109	+	(2) Permit each consumer who is a covered individual under the 76
	110	+	policy and legally capable of consenting to the provision of covered 77
	111	+	benefits to specify, in writing, that such insurer, center, corporation, 78
	112	+	society, entity or third-party administrator issue explanations of 79
	113	+	benefits concerning covered benefits provided to such consumer solely 80
	114	+	to such consumer, and specify, in writing, which of the following 81
	115	+	methods such insurer, center, corporation, society, entity or third-party 82
	116	+	administrator shall use to issue such explanations of benefits solely to 83
	117	+	such consumer: 84
	118	+	(A) Mailing such explanations of benefits to such consumer's mailing 85
	119	+	address or another mailing address specified by such consumer; 86
	120	+	(B) Sending such explanations of benefits to such consumer by 87
	121	+	electronic means, including, but not limited to, electronic mail; or 88
	122	+	(C) Making such explanations of benefits available to such consumer 89
	123	+	by electronic means, provided making such explanations of benefits 90
	124	+	available solely to such consumer by electronic means complies with all 91
	125	+	applicable federal and state laws and regulations concerning data 92
	126	+	security, including, but not limited to, 45 CFR Part 160, as amended from 93
	127	+	time to time, and 45 CFR Part 164, Subparts A and C, as amended from 94
	128	+	time to time. 95
	129	+	(e) Each method specified by a consumer, in writing, pursuant to 96
	130	+	subdivision (2) of subsection (d) of this section shall be valid until the 97
	131	+	consumer submits a written specification to the insurer, center, 98
	132	+	corporation, society, entity or third-party administrator for a different 99
	133	+	method. Such insurer, center, corporation, society, entity or third-party 100
	134	+	administrator shall comply with a written specification under this 101
	135	+	subsection or subdivision (2) of subsection (d) of this section, as 102
	136	+	applicable, not later than three business days after such insurer, center, 103
	137	+	corporation, society, entity or third-party administrator receives such 104 Substitute Bill No. 6389
156	138
157		-	unless such explanation is required by applicable law or pursuant to an
158		-	order issued by a court of competent jurisdiction.
159		-	(h) Each insurer, center, corporation, society or entity that delivers,
160		-	issues for delivery, renews, amends or continues a policy described in
161		-	subsection (a) of this section, and each third-party administrator
162		-	providing services to such insurer, center, corporation, society or entity,
163		-	shall disclose to each consumer who is a covered individual under the
164		-	policy such consumer's ability to submit specifications pursuant to
165		-	subsections (d) to (g), inclusive, of this section. Such disclosure shall be
166		-	in plain language and displayed or printed, as applicable, clearly and
167		-	conspicuously in all evidence of coverage documents, privacy
168		-	communications, explanations of benefits and Internet web sites that are
169		-	maintained by such insurer, center, corporation, society, entity or third-
170		-	party administrator and accessible to consumers in this state.
171		-	(i) No insurer, center, corporation, society or entity that is subject to
172		-	subsections (d) to (h), inclusive, of this section shall require a consumer
173		-	or policyholder to waive any right to limit disclosure under subsections
174		-	(d) to (h), inclusive, of this section as a precondition to delivering,
175		-	issuing for delivery, renewing, amending or continuing a policy
176		-	described in subsection (a) of this section to the consumer or
177		-	policyholder. Nothing in this subsection or subsections (d) to (h),
178		-	inclusive, of this section shall be construed to limit a consumer's or
179		-	policyholder's ability to request review of an adverse determination.
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	143	+
	144	+	specification. 105
	145	+	(f) Each insurer, center, corporation, society, entity or third-party 106
	146	+	administrator that receives a written specification from a consumer 107
	147	+	pursuant to subdivision (2) of subsection (d) of this section or subsection 108
	148	+	(e) of this section, as applicable, shall provide the consumer who made 109
	149	+	such specification with written confirmation that such insurer, center, 110
	150	+	corporation, society, entity or third-party administrator received such 111
	151	+	specification, and advise such consumer, in writing, regarding the status 112
	152	+	of such specification if such consumer contacts such insurer, center, 113
	153	+	corporation, society, entity or third-party administrator, in writing, 114
	154	+	regarding such specification. 115
	155	+	(g) Each consumer who is a covered individual under a policy 116
	156	+	described in subsection (a) of this section and is legally capable of 117
	157	+	consenting to the provision of covered benefits may specify, in writing, 118
	158	+	that the insurer, center, corporation, society or entity that delivered, 119
	159	+	issued for delivery, renewed, amended or continued the policy, or a 120
	160	+	third-party administrator providing services to such insurer, center, 121
	161	+	corporation, society or entity, not issue explanations of benefits 122
	162	+	pursuant to subsections (d) to (f), inclusive, of this section if such 123
	163	+	explanations of benefits concern covered benefits that were provided to 124
	164	+	such consumer. Such insurer, center, corporation, society, entity or 125
	165	+	third-party administrator shall not require such consumer to provide 126
	166	+	any explanation regarding the basis for such consumer's specification, 127
	167	+	unless such explanation is required by applicable law or pursuant to an 128
	168	+	order issued by a court of competent jurisdiction. 129
	169	+	(h) Each insurer, center, corporation, society or entity that delivers, 130
	170	+	issues for delivery, renews, amends or continues a policy described in 131
	171	+	subsection (a) of this section, and each third-party administrator 132
	172	+	providing services to such insurer, center, corporation, society or entity, 133
	173	+	shall disclose to each consumer who is a covered individual under the 134
	174	+	policy such consumer's ability to submit specifications pursuant to 135
	175	+	subsections (d) to (g), inclusive, of this section. Such disclosure shall be 136
	176	+	in plain language and displayed or printed, as applicable, clearly and 137 Substitute Bill No. 6389
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	182	+
	183	+	conspicuously in all evidence of coverage documents, privacy 138
	184	+	communications, explanations of benefits and Internet web sites that are 139
	185	+	maintained by such insurer, center, corporation, society, entity or third-140
	186	+	party administrator and accessible to consumers in this state. 141
	187	+	(i) No insurer, center, corporation, society or entity that is subject to 142
	188	+	subsections (d) to (h), inclusive, of this section shall require a consumer 143
	189	+	or policyholder to waive any right to limit disclosure under subsections 144
	190	+	(d) to (h), inclusive, of this section as a precondition to delivering, 145
	191	+	issuing for delivery, renewing, amending or continuing a policy 146
	192	+	described in subsection (a) of this section to the consumer or 147
	193	+	policyholder. Nothing in this subsection or subsections (d) to (h), 148
	194	+	inclusive, of this section shall be construed to limit a consumer's or 149
	195	+	policyholder's ability to request review of an adverse determination. 150
	196	+	This act shall take effect as follows and shall amend the following
	197	+	sections:
	198	+
	199	+	Section 1 January 1, 2023 38a-477d
	200	+
	201	+	Statement of Legislative Commissioners:
	202	+	In Subsec. (a)(1)(B), "subsections (d) to (i), inclusive," was substituted for
	203	+	"subsection (d)" for internal consistency; in Subsec. (d), Subsec. (d)(1)
	204	+	was redesignated Subsec. (d), Subsec. (d)(1)(A) was redesignated
	205	+	Subsec. (d)(1), Subsec. (d)(1)(B)(i) was redesignated Subsec. (d)(2),
	206	+	Subsec. (d)(1)(B)(i)(I) was redesignated Subsec. (d)(2)(A), Subsec.
	207	+	(d)(1)(B)(i)(II) was redesignated Subsec. (d)(2)(B), Subsec.
	208	+	(d)(1)(B)(i)(III) was redesignated Subsec. (d)(2)(C), Subsec. (d)(1)(B)(ii)
	209	+	was redesignated Subsec. (e), Subsec. (d)(1)(B)(iii) was redesignated
	210	+	Subsec. (f), Subsec. (d)(2) was redesignated Subsec. (g), Subsec. (d)(3)
	211	+	was redesignated Subsec. (h) and Subsec. (d)(4) was redesignated
	212	+	Subsec. (i) for consistency with standard drafting conventions; in
	213	+	Subsec. (d), "subsection (g) of this section" was substituted for
	214	+	"subdivision (2) of this subsection" for internal consistency; in Subsec.
	215	+	(e), "subdivision (2) of subsection (d) of this section" was substituted for
	216	+	"subparagraph (B)(i) of this subdivision", and "this subsection or
	217	+	subdivision (2) of subsection (d) of this section" was substituted for "this
	218	+	clause or subparagraph (B)(i) of this subdivision", for internal
	219	+	consistency; in Subsec. (f), "subdivision (2) of subsection (d) of this Substitute Bill No. 6389
	220	+
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	225	+
	226	+	section or subsection (e) of this section" was substituted for
	227	+	"subparagraph (B)(i) or (B)(ii) of this subdivision" for internal
	228	+	consistency; in Subsec. (g), "subsections (d) to (f), inclusive, of this
	229	+	section" was substituted for "subdivision (1) of this subsection" for
	230	+	internal consistency; in Subsec. (h), "subsections (d) to (g), inclusive, of
	231	+	this section" was substituted for "subdivisions (1) and (2) of this
	232	+	subsection" for internal consistency; and in Subsec. (i), "subsections (d)
	233	+	to (h), inclusive, of this section" was substituted for "this subsection" in
	234	+	two instances, and "or subsections (d) to (h), inclusive, of this section"
	235	+	was added, for internal consistency.
	236	+
	237	+	INS Joint Favorable Subst. -LCO
180	238