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General Assembly Raised Bill No. 1045
January Session, 2021
LCO No. 3686
Referred to Committee on INSURANCE AND REAL ESTATE
Introduced by:
(INS)
AN ACT CONCERNING ST EP THERAPY, ADVERSE DETERMINATION
AND UTILIZATION REVIEWS, AND HEALTH INSURANCE COV ERAGE
FOR CHILDREN, STEPCH ILDREN AND OTHER DEP ENDENT
CHILDREN.
Be it enacted by the Senate and House of Representatives in General
Assembly convened:
Section 1. Section 38a-497 of the general statutes is repealed and the 1
following is substituted in lieu thereof (Effective January 1, 2022): 2
Each individual health insurance policy providing coverage of the 3
type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 4
38a-469 delivered, issued for delivery, amended, renewed or continued 5
in this state shall provide that coverage of a child, stepchild or other 6
dependent child shall terminate [no] not earlier than the policy 7
anniversary date [on or] after [whichever of the following occurs first,] 8
the date on which the child, [: Becomes covered under a group health 9
plan through the dependent's own employment; or] stepchild or other 10
dependent child attains the age of twenty-six. Each such policy shall 11
cover a stepchild or other dependent child on the same basis as a 12
biological child. 13 Raised Bill No. 1045
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Sec. 2. Section 38a-512b of the general statutes is repealed and the 14
following is substituted in lieu thereof (Effective January 1, 2022): 15
Each group health insurance policy providing coverage of the type 16
specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-17
469 delivered, issued for delivery, amended, renewed or continued in 18
this state shall provide that coverage of a child, stepchild or other 19
dependent child shall terminate [no] not earlier than the policy 20
anniversary date [on or] after [whichever of the following occurs first,] 21
the date on which the child, [: Becomes covered under a group health 22
plan through the dependent's own employment; or] stepchild or other 23
dependent child attains the age of twenty-six. Each such policy shall 24
cover a stepchild or other dependent child on the same basis as a 25
biological child. 26
Sec. 3. Subsection (a) of section 38a-510 of the general statutes is 27
repealed and the following is substituted in lieu thereof (Effective January 28
1, 2022): 29
(a) No insurance company, hospital service corporation, medical 30
service corporation, health care center or other entity delivering, issuing 31
for delivery, renewing, amending or continuing an individual health 32
insurance policy or contract that provides coverage for prescription 33
drugs may: 34
(1) Require any person covered under such policy or contract to 35
obtain prescription drugs from a mail order pharmacy as a condition of 36
obtaining benefits for such drugs; or 37
(2) Require, if such insurance company, hospital service corporation, 38
medical service corporation, health care center or other entity uses step 39
therapy for such drugs, the use of step therapy for: 40
(A) [any] Any prescribed drug for longer than sixty days; [,] or 41
(B) [a] A prescribed drug for [cancer] treatment of a behavioral health 42
condition or a chronic, disabling or life-threatening condition or disease 43 Raised Bill No. 1045
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for an insured who has been diagnosed with [stage IV metastatic cancer] 44
such a condition or disease, provided such prescribed drug is in 45
compliance with approved federal Food and Drug Administration 46
indications. 47
(3) At the expiration of the time period specified in subparagraph (A) 48
of subdivision (2) of this subsection, [or for a prescribed drug described 49
in subparagraph (B) of subdivision (2) of this subsection,] an insured's 50
treating health care provider may deem such step therapy drug regimen 51
clinically ineffective for the insured, at which time the insurance 52
company, hospital service corporation, medical service corporation, 53
health care center or other entity shall authorize dispensation of and 54
coverage for the drug prescribed by the insured's treating health care 55
provider, provided such drug is a covered drug under such policy or 56
contract. If such provider does not deem such step therapy drug 57
regimen clinically ineffective or has not requested an override pursuant 58
to subdivision (1) of subsection (b) of this section, such drug regimen 59
may be continued. For purposes of this section, "step therapy" means a 60
protocol or program that establishes the specific sequence in which 61
prescription drugs for a specified medical condition are to be prescribed. 62
Sec. 4. Subsection (a) of section 38a-544 of the general statutes is 63
repealed and the following is substituted in lieu thereof (Effective January 64
1, 2022): 65
(a) No insurance company, hospital service corporation, medical 66
service corporation, health care center or other entity delivering, issuing 67
for delivery, renewing, amending or continuing a group health 68
insurance policy or contract that provides coverage for prescription 69
drugs may: 70
(1) Require any person covered under such policy or contract to 71
obtain prescription drugs from a mail order pharmacy as a condition of 72
obtaining benefits for such drugs; or 73
(2) Require, if such insurance company, hospital service corporation, 74
medical service corporation, health care center or other entity uses step 75 Raised Bill No. 1045
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therapy for such drugs, the use of step therapy for: 76
(A) [any] Any prescribed drug for longer than sixty days; [,] or 77
(B) [a] A prescribed drug for [cancer] treatment of a behavioral health 78
condition or a chronic, disabling or life-threatening condition or disease 79
for an insured who has been diagnosed with [stage IV metastatic cancer] 80
such a condition or disease, provided such prescribed drug is in 81
compliance with approved federal Food and Drug Administration 82
indications. 83
(3) At the expiration of the time period specified in subparagraph (A) 84
of subdivision (2) of this subsection, [or for a prescribed drug described 85
in subparagraph (B) of subdivision (2) of this subsection,] an insured's 86
treating health care provider may deem such step therapy drug regimen 87
clinically ineffective for the insured, at which time the insurance 88
company, hospital service corporation, medical service corporation, 89
health care center or other entity shall authorize dispensation of and 90
coverage for the drug prescribed by the insured's treating health care 91
provider, provided such drug is a covered drug under such policy or 92
contract. If such provider does not deem such step therapy drug 93
regimen clinically ineffective or has not requested an override pursuant 94
to subdivision (1) of subsection (b) of this section, such drug regimen 95
may be continued. For purposes of this section, "step therapy" means a 96
protocol or program that establishes the specific sequence in which 97
prescription drugs for a specified medical condition are to be prescribed. 98
Sec. 5. Subdivision (7) of section 38a-591a of the general statutes is 99
repealed and the following is substituted in lieu thereof (Effective January 100
1, 2022): 101
(7) "Clinical peer" means a physician or other health care professional 102
who: 103
(A) [holds] For a review other than as specified under subparagraph 104
(B) or (C) of subdivision (38) of this section: 105 Raised Bill No. 1045
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(i) Holds a nonrestricted license in a state of the United States [and] 106
in the same [or similar] specialty as [typically manages the medical 107
condition, procedure or treatment] the treating physician or other health 108
care professional under review; [, and] 109
(ii) Holds a doctoral or medical degree; and 110
(iii) (I) Holds an appropriate national board certification including at 111
the subspecialty level, where available, or (II) actively practices and 112
typically manages the medical condition under review or provides the 113
procedure or treatment under review; or 114
(B) [for] For a review specified under subparagraph (B) or (C) of 115
subdivision (38) of this section concerning: 116
(i) [a] A child or adolescent substance use disorder or a child or 117
adolescent mental disorder, holds (I) a national board certification in 118
child and adolescent psychiatry, or (II) a doctoral level psychology 119
degree with training and clinical experience in the treatment of child 120
and adolescent substance use disorder or child and adolescent mental 121
disorder, as applicable; [,] or 122
(ii) [an] An adult substance use disorder or an adult mental disorder, 123
holds (I) a national board certification in psychiatry, or (II) a doctoral 124
level psychology degree with training and clinical experience in the 125
treatment of adult substance use disorders or adult mental disorders, as 126
applicable. 127
Sec. 6. Subsection (a) of section 38a-591c of the general statutes is 128
repealed and the following is substituted in lieu thereof (Effective January 129
1, 2022): 130
(a) (1) Each health carrier shall contract with (A) health care 131
professionals to administer such health carrier's utilization review 132
program, and (B) clinical peers to evaluate the clinical appropriateness 133
of an adverse determination. 134
(2) (A) Each utilization review program shall use documented clinical 135 Raised Bill No. 1045
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review criteria that are based on sound clinical evidence and are 136
evaluated periodically by the health carrier's organizational mechanism 137
specified in subparagraph (F) of subdivision (2) of subsection (c) of 138
section 38a-591b to assure such program's ongoing effectiveness. 139
(B) Except as provided in subdivisions (3), (4) and (5) of this 140
subsection, a health carrier may develop its own clinical review criteria 141
or it may purchase or license clinical review criteria from qualified 142
vendors approved by the commissioner, provided such clinical review 143
criteria conform to the requirements of subparagraph (A) of this 144
subdivision. 145
(C) Each health carrier shall (i) post on its Internet web site (I) any 146
clinical review criteria it uses, and (II) links to any rule, guideline, 147
protocol or other similar criterion a health carrier may rely upon to make 148
an adverse determination as described in subparagraph (F) of 149
subdivision (1) of subsection (e) of section 38a-591d, as amended by this 150
act, and (ii) make its clinical review criteria available upon request to 151
authorized government agencies. 152
(D) For each utilization review, there shall be a rebuttable 153
presumption that each health care service under review is medically 154
necessary if such health care service was ordered by a health care 155
professional acting within the health care professional's scope of 156
practice. A health carrier, or any utilization review company or designee 157
of a health carrier that performs utilization review on behalf of the 158
health carrier, shall have the burden of proving that a health care service 159
is not medically necessary. 160
(3) For any utilization review for the treatment of a substance use 161
disorder, as described in section 17a-458, the clinical review criteria used 162
shall be: (A) The most recent edition of the American Society of 163
Addiction Medicine Treatment Criteria for Addictive, Substance-164
Related, and Co-Occurring Conditions; or (B) clinical review criteria that 165
the health carrier demonstrates to the Insurance Department is 166
consistent with the most recent edition of the American Society of 167 Raised Bill No. 1045
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Addiction Medicine Treatment Criteria for Addictive, Substance-168
Related, and Co-Occurring Conditions, except that nothing in this 169
subdivision shall prohibit a health carrier from developing its own 170
clinical review criteria or purchasing or licensing additional clinical 171
review criteria from qualified vendors approved by the commissioner, 172
to address advancements in technology or types of care for the 173
treatment of a substance use disorder, that are not covered in the most 174
recent edition of the American Society of Addiction Medicine Treatment 175
Criteria for Addictive, Substance-Related, and Co-Occurring 176
Conditions. Any such clinical review criteria developed by a health 177
carrier or purchased or licensed from a qualified vendor shall conform 178
to the requirements of subparagraph (A) of subdivision (2) of this 179
subsection. 180
(4) For any utilization review for the treatment of a child or 181
adolescent mental disorder, the clinical review criteria used shall be: (A) 182
The most recent guidelines of the American Academy of Child and 183
Adolescent Psychiatry's Child and Adolescent Service Intensity 184
Instrument; or (B) clinical review criteria that the health carrier 185
demonstrates to the Insurance Department is consistent with the most 186
recent guidelines of the American Academy of Child and Adolescent 187
Psychiatry's Child and Adolescent Service Intensity Instrument, except 188
that nothing in this subdivision shall prohibit a health carrier from 189
developing its own clinical review criteria or purchasing or licensing 190
additional clinical review criteria from qualified vendors approved by 191
the commissioner, to address advancements in technology or types of 192
care for the treatment of a child or adolescent mental disorder, that are 193
not covered in the most recent guidelines of the American Academy of 194
Child and Adolescent Psychiatry's Child and Adolescent Service 195
Intensity Instrument. Any such clinical review criteria developed by a 196
health carrier or purchased or licensed from a qualified vendor shall 197
conform to the requirements of subparagraph (A) of subdivision (2) of 198
this subsection. 199
(5) For any utilization review for the treatment of an adult mental 200
disorder, the clinical review criteria used shall be: (A) The most recent 201 Raised Bill No. 1045
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guidelines of the American Psychiatric Association or the most recent 202
Standards and Guidelines of the Association for Ambulatory Behavioral 203
Healthcare; or (B) clinical review criteria that the health carrier 204
demonstrates to the Insurance Department is consistent with the most 205
recent guidelines of the American Psychiatric Association or the most 206
recent Standards and Guidelines of the Association for Ambulatory 207
Behavioral Healthcare, except that nothing in this subdivision shall 208
prohibit a health carrier from developing its own clinical review criteria 209
or purchasing or licensing additional clinical review criteria from 210
qualified vendors approved by the commissioner, to address 211
advancements in technology or types of care for the treatment of an 212
adult mental disorder, that are not covered in the most recent guidelines 213
of the American Psychiatric Association or the most recent Standards 214
and Guidelines of the Association for Ambulatory Behavioral 215
Healthcare. Any such clinical review criteria developed by a health 216
carrier or purchased or licensed from a qualified vendor shall conform 217
to the requirements of subparagraph (A) of subdivision (2) of this 218
subsection. 219
Sec. 7. Subsection (a) of section 38a-591d of the general statutes is 220
repealed and the following is substituted in lieu thereof (Effective January 221
1, 2022): 222
(a) (1) Each health carrier shall maintain written procedures for (A) 223
utilization review and benefit determinations, (B) expedited utilization 224
review and benefit determinations with respect to prospective urgent 225
care requests and concurrent review urgent care requests, and (C) 226
notifying covered persons or covered persons' authorized 227
representatives of such review and benefit determinations. Each health 228
carrier shall make such review and benefit determinations within the 229
specified time periods under this section. 230
(2) In determining whether a benefit request shall be considered an 231
urgent care request, an individual acting on behalf of a health carrier 232
shall apply the judgment of a prudent layperson who possesses an 233
average knowledge of health and medicine, except that any benefit 234 Raised Bill No. 1045
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request (A) determined to be an urgent care request by a health care 235
professional with knowledge of the covered person's medical condition, 236
or (B) specified under subparagraph (B) or (C) of subdivision (38) of 237
section 38a-591a, as amended by this act, shall be deemed an urgent care 238
request. 239
(3) (A) At the time a health carrier notifies a covered person, a covered 240
person's authorized representative or a covered person's health care 241
professional of an initial adverse determination that was based, in whole 242
or in part, on medical necessity, of a concurrent or prospective 243
utilization review or of a benefit request, the health carrier shall notify 244
the covered person's health care professional (i) of the opportunity for a 245
conference as provided in subparagraph (B) of this subdivision, and (ii) 246
that such conference shall not be considered a grievance of such initial 247
adverse determination as long as a grievance has not been filed as set 248
forth in subparagraph (B) of this subdivision. 249
(B) After a health carrier notifies a covered person, a covered person's 250
authorized representative or a covered person's health care professional 251
of an initial adverse determination that was based, in whole or in part, 252
on medical necessity, of a concurrent or prospective utilization review 253
or of a benefit request, the health carrier shall offer a covered person's 254
health care professional the opportunity to confer, at the request of the 255
covered person's health care professional, with a clinical peer of such 256
health carrier, provided such covered person, covered person's 257
authorized representative or covered person's health care professional 258
has not filed a grievance of such initial adverse determination prior to 259
such conference. Such conference shall not be considered a grievance of 260
such initial adverse determination. Such health carrier shall grant such 261
clinical peer authority to reverse such initial adverse determination. 262
Sec. 8. Subsection (c) of section 38a-591e of the general statutes is 263
repealed and the following is substituted in lieu thereof (Effective January 264
1, 2022): 265
(c) (1) (A) When conducting a review of an adverse determination 266 Raised Bill No. 1045
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under this section, the health carrier shall ensure that such review is 267
conducted in a manner to ensure the independence and impartiality of 268
the clinical peer or peers involved in making the review decision. 269
(B) If the adverse determination involves utilization review, the 270
health carrier shall designate an appropriate clinical peer or peers to 271
review such adverse determination. Such clinical peer or peers shall not 272
have been involved in the initial adverse determination. 273
(C) (i) For each review of an adverse determination under this section, 274
there shall be a rebuttable presumption that each health care service 275
under review is medically necessary if such health care service was 276
ordered by a health care professional acting within the scope of the 277
health care professional's practice. The health carrier may rebut such 278
presumption by reasonably substantiating to the clinical peer or peers 279
conducting the review under this section that such health care service is 280
not medically necessary. 281
[(C)] (ii) The clinical peer or peers conducting a review under this 282
section shall take into consideration all comments, documents, records 283
and other information relevant to the covered person's benefit request 284
that is the subject of the adverse determination under review, that are 285
submitted by the covered person or the covered person's authorized 286
representative, regardless of whether such information was submitted 287
or considered in making the initial adverse determination. 288
(D) Prior to issuing a decision, the health carrier shall provide free of 289
charge, by facsimile, electronic means or any other expeditious method 290
available, to the covered person or the covered person's authorized 291
representative, as applicable, any new or additional documents, 292
communications, information and evidence relied upon and any new or 293
additional scientific or clinical rationale used by the health carrier in 294
connection with the grievance. Such documents, communications, 295
information, evidence and rationale shall be provided sufficiently in 296
advance of the date the health carrier is required to issue a decision to 297
permit the covered person or the covered person's authorized 298 Raised Bill No. 1045
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representative, as applicable, a reasonable opportunity to respond prior 299
to such date. 300
(2) If the review under subdivision (1) of this subsection is an 301
expedited review, all necessary information, including the health 302
carrier's decision, shall be transmitted between the health carrier and the 303
covered person or the covered person's authorized representative, as 304
applicable, by telephone, facsimile, electronic means or any other 305
expeditious method available. 306
(3) If the review under subdivision (1) of this subsection is an 307
expedited review of a grievance involving an adverse determination of 308
a concurrent review request, pursuant to 45 CFR 147.136, as amended 309
from time to time, the treatment shall be continued without liability to 310
the covered person until the covered person has been notified of the 311
review decision. 312
This act shall take effect as follows and shall amend the following
sections:
Section 1 January 1, 2022 38a-497
Sec. 2 January 1, 2022 38a-512b
Sec. 3 January 1, 2022 38a-510(a)
Sec. 4 January 1, 2022 38a-544(a)
Sec. 5 January 1, 2022 38a-591a(7)
Sec. 6 January 1, 2022 38a-591c(a)
Sec. 7 January 1, 2022 38a-591d(a)
Sec. 8 January 1, 2022 38a-591e(c)
Statement of Purpose:
To: (1) Allow a child, stepchild or other dependent child to retain health
insurance coverage under a parent's individual or group health
insurance policy until the policy anniversary date after the date on
which the child, stepchild or other dependent child attains the age of
twenty-six; (2) prohibit certain health carriers from requiring the use of
step therapy for drugs prescribed to treat behavioral health conditions
or chronic, disabling or life-threatening conditions or diseases; (3)
redefine "clinical peer" for the purposes of adverse determination and
utilization reviews; (4) require health carriers to bear the burden of Raised Bill No. 1045
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proving that certain health care services under adverse determination
or utilization review are not medically necessary; and (5) require health
carriers to provide certain clinical peers with the authority to reverse
initial adverse determinations.
[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.]