LCO No. 3653 1 of 7
General Assembly Raised Bill No. 1003
January Session, 2021
LCO No. 3653
Referred to Committee on INSURANCE AND REAL ESTATE
Introduced by:
(INS)
AN ACT PROHIBITING CERTAIN HEALTH CARRIE RS AND
PHARMACY BENEFITS MA NAGERS FROM EMPLOYING COPAY
ACCUMULATOR PROGRAMS .
Be it enacted by the Senate and House of Representatives in General
Assembly convened:
Section 1. Section 38a-1 of the general statutes is repealed and the 1
following is substituted in lieu thereof (Effective January 1, 2022): 2
Terms used in this title and sections 2, 4 and 5 of this act, unless it 3
appears from the context to the contrary, shall have a scope and 4
meaning as set forth in this section. 5
(1) "Affiliate" or "affiliated" means a person that directly, or indirectly 6
through one or more intermediaries, controls, is controlled by or is 7
under common control with another person. 8
(2) "Alien insurer" means any insurer that has been chartered by or 9
organized or constituted within or under the laws of any jurisdiction or 10
country without the United States. 11
(3) "Annuities" means all agreements to make periodical payments 12 Raised Bill No. 1003
LCO No. 3653 2 of 7
where the making or continuance of all or some of the series of the 13
payments, or the amount of the payment, is dependent upon the 14
continuance of human life or is for a specified term of years. This 15
definition does not apply to payments made under a policy of life 16
insurance. 17
(4) "Commissioner" means the Insurance Commissioner. 18
(5) "Control", "controlled by" or "under common control with" means 19
the possession, direct or indirect, of the power to direct or cause the 20
direction of the management and policies of a person, whether through 21
the ownership of voting securities, by contract other than a commercial 22
contract for goods or nonmanagement services, or otherwise, unless the 23
power is the result of an official position with the person. 24
(6) "Domestic insurer" means any insurer that has been chartered by, 25
incorporated, organized or constituted within or under the laws of this 26
state. 27
(7) "Domestic surplus lines insurer" means any domestic insurer that 28
has been authorized by the commissioner to write surplus lines 29
insurance. 30
(8) "Foreign country" means any jurisdiction not in any state, district 31
or territory of the United States. 32
(9) "Foreign insurer" means any insurer that has been chartered by or 33
organized or constituted within or under the laws of another state or a 34
territory of the United States. 35
(10) "Insolvency" or "insolvent" means, for any insurer, that it is 36
unable to pay its obligations when they are due, or when its admitted 37
assets do not exceed its liabilities plus the greater of: (A) Capital and 38
surplus required by law for its organization and continued operation; 39
or (B) the total par or stated value of its authorized and issued capital 40
stock. For purposes of this subdivision "liabilities" shall include but not 41
be limited to reserves required by statute or by regulations adopted by 42 Raised Bill No. 1003
LCO No. 3653 3 of 7
the commissioner in accordance with the provisions of chapter 54 or 43
specific requirements imposed by the commissioner upon a subject 44
company at the time of admission or subsequent thereto. 45
(11) "Insurance" means any agreement to pay a sum of money, 46
provide services or any other thing of value on the happening of a 47
particular event or contingency or to provide indemnity for loss in 48
respect to a specified subject by specified perils in return for a 49
consideration. In any contract of insurance, an insured shall have an 50
interest which is subject to a risk of loss through destruction or 51
impairment of that interest, which risk is assumed by the insurer and 52
such assumption shall be part of a general scheme to distribute losses 53
among a large group of persons bearing similar risks in return for a 54
ratable contribution or other consideration. 55
(12) "Insurer" or "insurance company" includes any person or 56
combination of persons doing any kind or form of insurance business 57
other than a fraternal benefit society, and shall include a receiver of any 58
insurer when the context reasonably permits. 59
(13) "Insured" means a person to whom or for whose benefit an 60
insurer makes a promise in an insurance policy. The term includes 61
policyholders, subscribers, members and beneficiaries. This definition 62
applies only to the provisions of this title and does not define the 63
meaning of this word as used in insurance policies or certificates. 64
(14) "Life insurance" means insurance on human lives and insurances 65
pertaining to or connected with human life. The business of life 66
insurance includes granting endowment benefits, granting additional 67
benefits in the event of death by accident or accidental means, granting 68
additional benefits in the event of the total and permanent disability of 69
the insured, and providing optional methods of settlement of proceeds. 70
Life insurance includes burial contracts to the extent provided by 71
section 38a-464. 72
(15) "Mutual insurer" means any insurer without capital stock, the 73
managing directors or officers of which are elected by its members. 74 Raised Bill No. 1003
LCO No. 3653 4 of 7
(16) "Person" means an individual, a corporation, a partnership, a 75
limited liability company, an association, a joint stock company, a 76
business trust, an unincorporated organization or other legal entity. 77
(17) "Policy" means any document, including attached endorsements 78
and riders, purporting to be an enforceable contract, which 79
memorializes in writing some or all of the terms of an insurance 80
contract. 81
(18) "State" means any state, district, or territory of the United States. 82
(19) "Subsidiary" of a specified person means an affiliate controlled 83
by the person directly, or indirectly through one or more intermediaries. 84
(20) "Unauthorized insurer" or "nonadmitted insurer" means an 85
insurer that has not been granted a certificate of authority by the 86
commissioner to transact the business of insurance in this state or an 87
insurer transacting business not authorized by a valid certificate. 88
(21) "United States" means the United States of America, its territories 89
and possessions, the Commonwealth of Puerto Rico and the District of 90
Columbia. 91
Sec. 2. (NEW) (Effective January 1, 2022) Each insurer, health care 92
center, hospital service corporation, medical service corporation, 93
fraternal benefit society or other entity that delivers, issues for delivery, 94
renews, amends or continues an individual or group health insurance 95
policy in this state on or after January 1, 2022, providing coverage of the 96
type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 97
of the general statutes shall, when calculating an insured's liability for a 98
coinsurance, copayment, deductible or other out-of-pocket expense for 99
a covered benefit, give credit for any payment made by a third party for 100
the amount of, or any portion of the amount of, the coinsurance, 101
copayment, deductible or other out-of-pocket expense for the covered 102
benefit. 103
Sec. 3. Section 38a-478 of the general statutes is repealed and the 104 Raised Bill No. 1003
LCO No. 3653 5 of 7
following is substituted in lieu thereof (Effective January 1, 2022): 105
As used in this section, sections 38a-478a to 38a-478o, inclusive, [and] 106
subsection (a) of section 38a-478s and section 4 of this act: 107
(1) "Commissioner" means the Insurance Commissioner. 108
(2) "Covered benefit" or "benefit" means a health care service to which 109
an enrollee is entitled under the terms of a health benefit plan. 110
(3) "Enrollee" means a person who has contracted for or who 111
participates in a managed care plan for such person or such person's 112
eligible dependents. 113
(4) "Health care services" means services for the diagnosis, 114
prevention, treatment, cure or relief of a health condition, illness, injury 115
or disease. 116
(5) "Managed care organization" means an insurer, health care center, 117
hospital service corporation, medical service corporation or other 118
organization delivering, issuing for delivery, renewing, amending or 119
continuing any individual or group health managed care plan in this 120
state. 121
(6) "Managed care plan" means a product offered by a managed care 122
organization that provides for the financing or delivery of health care 123
services to persons enrolled in the plan through: (A) Arrangements with 124
selected providers to furnish health care services; (B) explicit standards 125
for the selection of participating providers; (C) financial incentives for 126
enrollees to use the participating providers and procedures provided for 127
by the plan; or (D) arrangements that share risks with providers, 128
provided the organization offering a plan described under 129
subparagraph (A), (B), (C) or (D) of this subdivision is licensed by the 130
Insurance Department pursuant to chapter 698, 698a or 700 and the plan 131
includes utilization review, as defined in section 38a-591a. 132
(7) "Preferred provider network" has the same meaning as provided 133
in section 38a-479aa. 134 Raised Bill No. 1003
LCO No. 3653 6 of 7
(8) "Provider" or "health care provider" means a person licensed to 135
provide health care services under chapters 370 to 373, inclusive, 375 to 136
383c, inclusive, 384a to 384c, inclusive, or chapter 400j. 137
(9) "Utilization review" has the same meaning as provided in section 138
38a-591a. 139
(10) "Utilization review company" has the same meaning as provided 140
in section 38a-591a. 141
Sec. 4. (NEW) (Effective January 1, 2022) For any contract delivered, 142
issued for delivery, renewed, amended or continued in this state on or 143
after January 1, 2022, each managed care organization shall, when 144
calculating an enrollee's liability for a coinsurance, copayment, 145
deductible or other out-of-pocket expense for a covered benefit, give 146
credit for any payment made by a third party for the amount of, or any 147
portion of the amount of, the coinsurance, copayment, deductible or 148
other out-of-pocket expense for the covered benefit. 149
Sec. 5. (NEW) (Effective January 1, 2022) On and after January 1, 2022, 150
each contract entered into between a health carrier, as defined in section 151
38a-591a of the general statutes, and a pharmacy benefits manager, as 152
defined in section 38a-479aaa of the general statutes, for the 153
administration of the pharmacy benefit portion of a health benefit plan 154
in this state on behalf of plan sponsors shall require that the pharmacy 155
benefits manager, when calculating an insured's or enrollee's liability for 156
a coinsurance, copayment, deductible or other out-of-pocket expense for 157
a covered prescription drug benefit, give credit for any payment made 158
by a third party for the amount of, or any portion of the amount of, the 159
coinsurance, copayment, deductible or other out-of-pocket expense for 160
the covered prescription drug benefit. 161
This act shall take effect as follows and shall amend the following
sections:
Section 1 January 1, 2022 38a-1
Sec. 2 January 1, 2022 New section
Sec. 3 January 1, 2022 38a-478 Raised Bill No. 1003
LCO No. 3653 7 of 7
Sec. 4 January 1, 2022 New section
Sec. 5 January 1, 2022 New section
Statement of Purpose:
To require certain health carriers and pharmacy benefits managers to
give credit for payments made by third parties for the amount of, or any
portion of the amount of, an insured's or enrollee's cost-sharing liability
for a covered benefit.
[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.]