Researcher: AR Page 1 4/8/21
OLR Bill Analysis
SB 1045
AN ACT CONCERNING STEP THERAPY, ADVERSE
DETERMINATION AND UTILIZATION REVIEWS, AND HEALTH
INSURANCE COVERAGE FOR CHILDREN, STEPCHILDREN AND
OTHER DEPENDENT CHILDREN.
SUMMARY
This bill establishes a rebuttable presumption in a utilization or
adverse determination review that a health care service ordered by a
health professional acting within his or her scope of practice is
medically necessary. For utilization reviews, the bill imposes on
carriers or utilization review companies the burden of proving a health
care service is not medically necessary. For adverse determination
reviews, a carrier may rebut the assumption by reasonably
substantiating to the clinical peers conducting the review that the
service is not medically necessary. (Utilization and adverse
determination reviews are steps in determining whether a specific
service is covered and reimbursed, see BACKGROUND.)
The bill also expands current law’s prohibition on step therapy to
include prescription drugs prescribed to treat a behavioral health
condition or a disabling, chronic, or life-threatening condition or
disease.
The bill increases the education requirements to qualify as a clinical
peer for utilization and adverse determination reviews unrelated to the
urgent treatment of substance use or mental disorders, generally
aligning them with the requirements for clinical peers that do treat
those reviews. It also requires health carriers to authorize clinical peers
to reverse initial adverse determinations.
Current law requires certain health insurance policies to cover
children until age 26, or earlier if they receive coverage through their
employer. The bill instead requires policies to cover them until age 26 2021SB-01045-R000370-BA.DOCX
Researcher: AR Page 2 4/8/21
regardless of whether they have coverage through their employer, and
it extends this requirement to stepchildren and other dependent
children.
EFFECTIVE DATE: January 1, 2022
§§ 3 & 4 — STEP THERAPY
Step therapy is a protocol establishing the sequence for prescribing
drugs for specific medical conditions that generally requires patients to
try less expensive drugs before higher cost drugs. The bill prohibits
health insurers from requiring an insured to use step therapy for
prescribed drugs to treat a behavioral health condition or a disabling,
chronic, or life-threatening condition or disease, provided the drug is
prescribed in accordance with federal Food and Drug Administration
indications. Current law limits this prohibition to drugs used to treat
stage IV metastatic cancer. By law, step therapy cannot be used for
longer than 60 days.
§§ 1 & 2 — DEPENDENT CHILDREN C OVERAGE
The bill requires certain health insurance policies to cover
stepchildren and other dependent children until the policy anniversary
date after they turn 26 years old. The provisions apply to fully insured
individual and group coverage health insurance policies delivered,
issued, renewed, amended, or continued in Connecticut that cover (1)
basic hospital expenses; (2) basic medical-surgical expenses; (3) major
medical expenses; or (4) hospital or medical services, including those
provided under an HMO plan. It also applies to individual health
insurance policies that cover (1) limited benefits and (2) accidents only.
The bill also eliminates a provision allowing these health plans to
terminate coverage for children before they reach age 26 if they
become covered through their own employment.
(Because of the federal Employee Retirement Income Security Act
(ERISA), state insurance benefit mandates do not apply to self-insured
benefit plans.)
§ 5 — REQUIREMENTS FOR CLI NICAL PEERS 2021SB-01045-R000370-BA.DOCX
Researcher: AR Page 3 4/8/21
Under current law, clinical peers conducting utilization or adverse
determination reviews unrelated to the urgent treatment of substance
use or mental disorders must have a nonrestricted license in the same
or similar specialty that typically manages the medical condition,
procedures, or treatment under review. The bill instead requires these
clinical peers to have a nonrestricted license in the same specialty.
Additionally, these clinical peers must have:
1. a doctoral or medical degree; and
2. either an appropriate national board certification, including at
the subspecialty level if possible, or actively practice and
typically manage the condition or procedure under review.
BACKGROUND
Utilization and Adverse Determination Reviews
Generally, reviews have up to three steps: (1) an initial utilization
review to determine if the procedure is covered; (2) a grievance review
(i.e., internal review), which occurs when a covered person appeals a
benefit denial (i.e., adverse determination); and (3) an external review,
which is conducted when a covered person exhausts a health carrier’s
internal process and appeals the carrier’s adverse determination to the
insurance department. External reviews, also called final adverse
determination reviews, are conducted by an independent review
organization assigned by the insurance department.
COMMITTEE ACTION
Insurance and Real Estate Committee
Joint Favorable
Yea 15 Nay 3 (03/22/2021)