Connecticut 2021 Regular Session

Connecticut Senate Bill SB01045 Compare Versions

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Version 2 (New)

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7	7		General Assembly Raised Bill No. 1045
8	8		January Session, 2021
9	9		LCO No. 3686
10	10
11	11
12	12		Referred to Committee on INSURANCE AND REAL ESTATE
13	13
14	14
15	15		Introduced by:
16	16		(INS)
17	17
18	18
19	19
20	20		AN ACT CONCERNING ST EP THERAPY, ADVERSE DETERMINATION
21	21		AND UTILIZATION REVIEWS, AND HEALTH INSURANCE COVERAGE
22	22		FOR CHILDREN, STEPCH ILDREN AND OTHER DEP ENDENT
23	23		CHILDREN.
24	24		Be it enacted by the Senate and House of Representatives in General
25	25		Assembly convened:
26	26
27	27		Section 1. Section 38a-497 of the general statutes is repealed and the 1
28	28		following is substituted in lieu thereof (Effective January 1, 2022): 2
29	29		Each individual health insurance policy providing coverage of the 3
30	30		type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 4
31	31		38a-469 delivered, issued for delivery, amended, renewed or continued 5
32	32		in this state shall provide that coverage of a child, stepchild or other 6
33	33		dependent child shall terminate [no] not earlier than the policy 7
34	34		anniversary date [on or] after [whichever of the following occurs first,] 8
35	35		the date on which the child, [: Becomes covered under a group health 9
36	36		plan through the dependent's own employment; or] stepchild or other 10
37	37		dependent child attains the age of twenty-six. Each such policy shall 11
38	38		cover a stepchild or other dependent child on the same basis as a 12
39	39		biological child. 13 Raised Bill No. 1045
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45	45
46	46		Sec. 2. Section 38a-512b of the general statutes is repealed and the 14
47	47		following is substituted in lieu thereof (Effective January 1, 2022): 15
48	48		Each group health insurance policy providing coverage of the type 16
49	49		specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-17
50	50		469 delivered, issued for delivery, amended, renewed or continued in 18
51	51		this state shall provide that coverage of a child, stepchild or other 19
52	52		dependent child shall terminate [no] not earlier than the policy 20
53	53		anniversary date [on or] after [whichever of the following occurs first,] 21
54	54		the date on which the child, [: Becomes covered under a group health 22
55	55		plan through the dependent's own employment; or] stepchild or other 23
56	56		dependent child attains the age of twenty-six. Each such policy shall 24
57	57		cover a stepchild or other dependent child on the same basis as a 25
58	58		biological child. 26
59	59		Sec. 3. Subsection (a) of section 38a-510 of the general statutes is 27
60	60		repealed and the following is substituted in lieu thereof (Effective January 28
61	61		1, 2022): 29
62	62		(a) No insurance company, hospital service corporation, medical 30
63	63		service corporation, health care center or other entity delivering, issuing 31
64	64		for delivery, renewing, amending or continuing an individual health 32
65	65		insurance policy or contract that provides coverage for prescription 33
66	66		drugs may: 34
67	67		(1) Require any person covered under such policy or contract to 35
68	68		obtain prescription drugs from a mail order pharmacy as a condition of 36
69	69		obtaining benefits for such drugs; or 37
70	70		(2) Require, if such insurance company, hospital service corporation, 38
71	71		medical service corporation, health care center or other entity uses step 39
72	72		therapy for such drugs, the use of step therapy for: 40
73	73		(A) [any] Any prescribed drug for longer than sixty days; [,] or 41
74	74		(B) [a] A prescribed drug for [cancer] treatment of a behavioral health 42
75	75		condition or a chronic, disabling or life-threatening condition or disease 43 Raised Bill No. 1045
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81	81
82	82		for an insured who has been diagnosed with [stage IV metastatic cancer] 44
83	83		such a condition or disease, provided such prescribed drug is in 45
84	84		compliance with approved federal Food and Drug Administration 46
85	85		indications. 47
86	86		(3) At the expiration of the time period specified in subparagraph (A) 48
87	87		of subdivision (2) of this subsection, [or for a prescribed drug described 49
88	88		in subparagraph (B) of subdivision (2) of this subsection,] an insured's 50
89	89		treating health care provider may deem such step therapy drug regimen 51
90	90		clinically ineffective for the insured, at which time the insurance 52
91	91		company, hospital service corporation, medical service corporation, 53
92	92		health care center or other entity shall authorize dispensation of and 54
93	93		coverage for the drug prescribed by the insured's treating health care 55
94	94		provider, provided such drug is a covered drug under such policy or 56
95	95		contract. If such provider does not deem such step therapy drug 57
96	96		regimen clinically ineffective or has not requested an override pursuant 58
97	97		to subdivision (1) of subsection (b) of this section, such drug regimen 59
98	98		may be continued. For purposes of this section, "step therapy" means a 60
99	99		protocol or program that establishes the specific sequence in which 61
100	100		prescription drugs for a specified medical condition are to be prescribed. 62
101	101		Sec. 4. Subsection (a) of section 38a-544 of the general statutes is 63
102	102		repealed and the following is substituted in lieu thereof (Effective January 64
103	103		1, 2022): 65
104	104		(a) No insurance company, hospital service corporation, medical 66
105	105		service corporation, health care center or other entity delivering, issuing 67
106	106		for delivery, renewing, amending or continuing a group health 68
107	107		insurance policy or contract that provides coverage for prescription 69
108	108		drugs may: 70
109	109		(1) Require any person covered under such policy or contract to 71
110	110		obtain prescription drugs from a mail order pharmacy as a condition of 72
111	111		obtaining benefits for such drugs; or 73
112	112		(2) Require, if such insurance company, hospital service corporation, 74 Raised Bill No. 1045
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119	119		medical service corporation, health care center or other entity uses step 75
120	120		therapy for such drugs, the use of step therapy for: 76
121	121		(A) [any] Any prescribed drug for longer than sixty days; [,] or 77
122	122		(B) [a] A prescribed drug for [cancer] treatment of a behavioral health 78
123	123		condition or a chronic, disabling or life-threatening condition or disease 79
124	124		for an insured who has been diagnosed with [stage IV metastatic cancer] 80
125	125		such a condition or disease, provided such prescribed drug is in 81
126	126		compliance with approved federal Food and Drug Administration 82
127	127		indications. 83
128	128		(3) At the expiration of the time period specified in subparagraph (A) 84
129	129		of subdivision (2) of this subsection, [or for a prescribed drug described 85
130	130		in subparagraph (B) of subdivision (2) of this subsection,] an insured's 86
131	131		treating health care provider may deem such step therapy drug regimen 87
132	132		clinically ineffective for the insured, at which time the insurance 88
133	133		company, hospital service corporation, medical service corporation, 89
134	134		health care center or other entity shall authorize dispensation of and 90
135	135		coverage for the drug prescribed by the insured's treating health care 91
136	136		provider, provided such drug is a covered drug under such policy or 92
137	137		contract. If such provider does not deem such step therapy drug 93
138	138		regimen clinically ineffective or has not requested an override pursuant 94
139	139		to subdivision (1) of subsection (b) of this section, such drug regimen 95
140	140		may be continued. For purposes of this section, "step therapy" means a 96
141	141		protocol or program that establishes the specific sequence in which 97
142	142		prescription drugs for a specified medical condition are to be prescribed. 98
143	143		Sec. 5. Subdivision (7) of section 38a-591a of the general statutes is 99
144	144		repealed and the following is substituted in lieu thereof (Effective January 100
145	145		1, 2022): 101
146	146		(7) "Clinical peer" means a physician or other health care professional 102
147	147		who: 103
148	148		(A) [holds] For a review other than as specified under subparagraph 104
149	149		(B) or (C) of subdivision (38) of this section: 105 Raised Bill No. 1045
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156	156		(i) Holds a nonrestricted license in a state of the United States [and] 106
157	157		in the same [or similar] specialty as [typically manages the medical 107
158	158		condition, procedure or treatment] the treating physician or other health 108
159	159		care professional under review; [, and] 109
160	160		(ii) Holds a doctoral or medical degree; and 110
161	161		(iii) (I) Holds an appropriate national board certification including at 111
162	162		the subspecialty level, where available, or (II) actively practices and 112
163	163		typically manages the medical condition under review or provides the 113
164	164		procedure or treatment under review; or 114
165	165		(B) [for] For a review specified under subparagraph (B) or (C) of 115
166	166		subdivision (38) of this section concerning: 116
167	167		(i) [a] A child or adolescent substance use disorder or a child or 117
168	168		adolescent mental disorder, holds (I) a national board certification in 118
169	169		child and adolescent psychiatry, or (II) a doctoral level psychology 119
170	170		degree with training and clinical experience in the treatment of child 120
171	171		and adolescent substance use disorder or child and adolescent mental 121
172	172		disorder, as applicable; [,] or 122
173	173		(ii) [an] An adult substance use disorder or an adult mental disorder, 123
174	174		holds (I) a national board certification in psychiatry, or (II) a doctoral 124
175	175		level psychology degree with training and clinical experience in the 125
176	176		treatment of adult substance use disorders or adult mental disorders, as 126
177	177		applicable. 127
178	178		Sec. 6. Subsection (a) of section 38a-591c of the general statutes is 128
179	179		repealed and the following is substituted in lieu thereof (Effective January 129
180	180		1, 2022): 130
181	181		(a) (1) Each health carrier shall contract with (A) health care 131
182	182		professionals to administer such health carrier's utilization review 132
183	183		program, and (B) clinical peers to evaluate the clinical appropriateness 133
184	184		of an adverse determination. 134 Raised Bill No. 1045
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190	190
191	191		(2) (A) Each utilization review program shall use documented clinical 135
192	192		review criteria that are based on sound clinical evidence and are 136
193	193		evaluated periodically by the health carrier's organizational mechanism 137
194	194		specified in subparagraph (F) of subdivision (2) of subsection (c) of 138
195	195		section 38a-591b to assure such program's ongoing effectiveness. 139
196	196		(B) Except as provided in subdivisions (3), (4) and (5) of this 140
197	197		subsection, a health carrier may develop its own clinical review criteria 141
198	198		or it may purchase or license clinical review criteria from qualified 142
199	199		vendors approved by the commissioner, provided such clinical review 143
200	200		criteria conform to the requirements of subparagraph (A) of this 144
201	201		subdivision. 145
202	202		(C) Each health carrier shall (i) post on its Internet web site (I) any 146
203	203		clinical review criteria it uses, and (II) links to any rule, guideline, 147
204	204		protocol or other similar criterion a health carrier may rely upon to make 148
205	205		an adverse determination as described in subparagraph (F) of 149
206	206		subdivision (1) of subsection (e) of section 38a-591d, as amended by this 150
207	207		act, and (ii) make its clinical review criteria available upon request to 151
208	208		authorized government agencies. 152
209	209		(D) For each utilization review, there shall be a rebuttable 153
210	210		presumption that each health care service under review is medically 154
211	211		necessary if such health care service was ordered by a health care 155
212	212		professional acting within the health care professional's scope of 156
213	213		practice. A health carrier, or any utilization review company or designee 157
214	214		of a health carrier that performs utilization review on behalf of the 158
215	215		health carrier, shall have the burden of proving that a health care service 159
216	216		is not medically necessary. 160
217	217		(3) For any utilization review for the treatment of a substance use 161
218	218		disorder, as described in section 17a-458, the clinical review criteria used 162
219	219		shall be: (A) The most recent edition of the American Society of 163
220	220		Addiction Medicine Treatment Criteria for Addictive, Substance-164
221	221		Related, and Co-Occurring Conditions; or (B) clinical review criteria that 165
222	222		the health carrier demonstrates to the Insurance Department is 166 Raised Bill No. 1045
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228	228
229	229		consistent with the most recent edition of the American Society of 167
230	230		Addiction Medicine Treatment Criteria for Addictive, Substance-168
231	231		Related, and Co-Occurring Conditions, except that nothing in this 169
232	232		subdivision shall prohibit a health carrier from developing its own 170
233	233		clinical review criteria or purchasing or licensing additional clinical 171
234	234		review criteria from qualified vendors approved by the commissioner, 172
235	235		to address advancements in technology or types of care for the 173
236	236		treatment of a substance use disorder, that are not covered in the most 174
237	237		recent edition of the American Society of Addiction Medicine Treatment 175
238	238		Criteria for Addictive, Substance-Related, and Co-Occurring 176
239	239		Conditions. Any such clinical review criteria developed by a health 177
240	240		carrier or purchased or licensed from a qualified vendor shall conform 178
241	241		to the requirements of subparagraph (A) of subdivision (2) of this 179
242	242		subsection. 180
243	243		(4) For any utilization review for the treatment of a child or 181
244	244		adolescent mental disorder, the clinical review criteria used shall be: (A) 182
245	245		The most recent guidelines of the American Academy of Child and 183
246	246		Adolescent Psychiatry's Child and Adolescent Service Intensity 184
247	247		Instrument; or (B) clinical review criteria that the health carrier 185
248	248		demonstrates to the Insurance Department is consistent with the most 186
249	249		recent guidelines of the American Academy of Child and Adolescent 187
250	250		Psychiatry's Child and Adolescent Service Intensity Instrument, except 188
251	251		that nothing in this subdivision shall prohibit a health carrier from 189
252	252		developing its own clinical review criteria or purchasing or licensing 190
253	253		additional clinical review criteria from qualified vendors approved by 191
254	254		the commissioner, to address advancements in technology or types of 192
255	255		care for the treatment of a child or adolescent mental disorder, that are 193
256	256		not covered in the most recent guidelines of the American Academy of 194
257	257		Child and Adolescent Psychiatry's Child and Adolescent Service 195
258	258		Intensity Instrument. Any such clinical review criteria developed by a 196
259	259		health carrier or purchased or licensed from a qualified vendor shall 197
260	260		conform to the requirements of subparagraph (A) of subdivision (2) of 198
261	261		this subsection. 199 Raised Bill No. 1045
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268	268		(5) For any utilization review for the treatment of an adult mental 200
269	269		disorder, the clinical review criteria used shall be: (A) The most recent 201
270	270		guidelines of the American Psychiatric Association or the most recent 202
271	271		Standards and Guidelines of the Association for Ambulatory Behavioral 203
272	272		Healthcare; or (B) clinical review criteria that the health carrier 204
273	273		demonstrates to the Insurance Department is consistent with the most 205
274	274		recent guidelines of the American Psychiatric Association or the most 206
275	275		recent Standards and Guidelines of the Association for Ambulatory 207
276	276		Behavioral Healthcare, except that nothing in this subdivision shall 208
277	277		prohibit a health carrier from developing its own clinical review criteria 209
278	278		or purchasing or licensing additional clinical review criteria from 210
279	279		qualified vendors approved by the commissioner, to address 211
280	280		advancements in technology or types of care for the treatment of an 212
281	281		adult mental disorder, that are not covered in the most recent guidelines 213
282	282		of the American Psychiatric Association or the most recent Standards 214
283	283		and Guidelines of the Association for Ambulatory Behavioral 215
284	284		Healthcare. Any such clinical review criteria developed by a health 216
285	285		carrier or purchased or licensed from a qualified vendor shall conform 217
286	286		to the requirements of subparagraph (A) of subdivision (2) of this 218
287	287		subsection. 219
288	288		Sec. 7. Subsection (a) of section 38a-591d of the general statutes is 220
289	289		repealed and the following is substituted in lieu thereof (Effective January 221
290	290		1, 2022): 222
291	291		(a) (1) Each health carrier shall maintain written procedures for (A) 223
292	292		utilization review and benefit determinations, (B) expedited utilization 224
293	293		review and benefit determinations with respect to prospective urgent 225
294	294		care requests and concurrent review urgent care requests, and (C) 226
295	295		notifying covered persons or covered persons' authorized 227
296	296		representatives of such review and benefit determinations. Each health 228
297	297		carrier shall make such review and benefit determinations within the 229
298	298		specified time periods under this section. 230
299	299		(2) In determining whether a benefit request shall be considered an 231
300	300		urgent care request, an individual acting on behalf of a health carrier 232 Raised Bill No. 1045
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307	307		shall apply the judgment of a prudent layperson who possesses an 233
308	308		average knowledge of health and medicine, except that any benefit 234
309	309		request (A) determined to be an urgent care request by a health care 235
310	310		professional with knowledge of the covered person's medical condition, 236
311	311		or (B) specified under subparagraph (B) or (C) of subdivision (38) of 237
312	312		section 38a-591a, as amended by this act, shall be deemed an urgent care 238
313	313		request. 239
314	314		(3) (A) At the time a health carrier notifies a covered person, a covered 240
315	315		person's authorized representative or a covered person's health care 241
316	316		professional of an initial adverse determination that was based, in whole 242
317	317		or in part, on medical necessity, of a concurrent or prospective 243
318	318		utilization review or of a benefit request, the health carrier shall notify 244
319	319		the covered person's health care professional (i) of the opportunity for a 245
320	320		conference as provided in subparagraph (B) of this subdivision, and (ii) 246
321	321		that such conference shall not be considered a grievance of such initial 247
322	322		adverse determination as long as a grievance has not been filed as set 248
323	323		forth in subparagraph (B) of this subdivision. 249
324	324		(B) After a health carrier notifies a covered person, a covered person's 250
325	325		authorized representative or a covered person's health care professional 251
326	326		of an initial adverse determination that was based, in whole or in part, 252
327	327		on medical necessity, of a concurrent or prospective utilization review 253
328	328		or of a benefit request, the health carrier shall offer a covered person's 254
329	329		health care professional the opportunity to confer, at the request of the 255
330	330		covered person's health care professional, with a clinical peer of such 256
331	331		health carrier, provided such covered person, covered person's 257
332	332		authorized representative or covered person's health care professional 258
333	333		has not filed a grievance of such initial adverse determination prior to 259
334	334		such conference. Such conference shall not be considered a grievance of 260
335	335		such initial adverse determination. Such health carrier shall grant such 261
336	336		clinical peer authority to reverse such initial adverse determination. 262
337	337		Sec. 8. Subsection (c) of section 38a-591e of the general statutes is 263
338	338		repealed and the following is substituted in lieu thereof (Effective January 264
339	339		1, 2022): 265 Raised Bill No. 1045
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346	346		(c) (1) (A) When conducting a review of an adverse determination 266
347	347		under this section, the health carrier shall ensure that such review is 267
348	348		conducted in a manner to ensure the independence and impartiality of 268
349	349		the clinical peer or peers involved in making the review decision. 269
350	350		(B) If the adverse determination involves utilization review, the 270
351	351		health carrier shall designate an appropriate clinical peer or peers to 271
352	352		review such adverse determination. Such clinical peer or peers shall not 272
353	353		have been involved in the initial adverse determination. 273
354	354		(C) (i) For each review of an adverse determination under this section, 274
355	355		there shall be a rebuttable presumption that each health care service 275
356	356		under review is medically necessary if such health care service was 276
357	357		ordered by a health care professional acting within the scope of the 277
358	358		health care professional's practice. The health carrier may rebut such 278
359	359		presumption by reasonably substantiating to the clinical peer or peers 279
360	360		conducting the review under this section that such health care service is 280
361	361		not medically necessary. 281
362	362		[(C)] (ii) The clinical peer or peers conducting a review under this 282
363	363		section shall take into consideration all comments, documents, records 283
364	364		and other information relevant to the covered person's benefit request 284
365	365		that is the subject of the adverse determination under review, that are 285
366	366		submitted by the covered person or the covered person's authorized 286
367	367		representative, regardless of whether such information was submitted 287
368	368		or considered in making the initial adverse determination. 288
369	369		(D) Prior to issuing a decision, the health carrier shall provide free of 289
370	370		charge, by facsimile, electronic means or any other expeditious method 290
371	371		available, to the covered person or the covered person's authorized 291
372	372		representative, as applicable, any new or additional documents, 292
373	373		communications, information and evidence relied upon and any new or 293
374	374		additional scientific or clinical rationale used by the health carrier in 294
375	375		connection with the grievance. Such documents, communications, 295
376	376		information, evidence and rationale shall be provided sufficiently in 296
377	377		advance of the date the health carrier is required to issue a decision to 297 Raised Bill No. 1045
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383	383
384	384		permit the covered person or the covered person's authorized 298
385	385		representative, as applicable, a reasonable opportunity to respond prior 299
386	386		to such date. 300
387	387		(2) If the review under subdivision (1) of this subsection is an 301
388	388		expedited review, all necessary information, including the health 302
389	389		carrier's decision, shall be transmitted between the health carrier and the 303
390	390		covered person or the covered person's authorized representative, as 304
391	391		applicable, by telephone, facsimile, electronic means or any other 305
392	392		expeditious method available. 306
393	393		(3) If the review under subdivision (1) of this subsection is an 307
394	394		expedited review of a grievance involving an adverse determination of 308
395	395		a concurrent review request, pursuant to 45 CFR 147.136, as amended 309
396	396		from time to time, the treatment shall be continued without liability to 310
397	397		the covered person until the covered person has been notified of the 311
398	398		review decision. 312
399	399		This act shall take effect as follows and shall amend the following
400	400		sections:
401	401
402	402		Section 1 January 1, 2022 38a-497
403	403		Sec. 2 January 1, 2022 38a-512b
404	404		Sec. 3 January 1, 2022 38a-510(a)
405	405		Sec. 4 January 1, 2022 38a-544(a)
406	406		Sec. 5 January 1, 2022 38a-591a(7)
407	407		Sec. 6 January 1, 2022 38a-591c(a)
408	408		Sec. 7 January 1, 2022 38a-591d(a)
409	409		Sec. 8 January 1, 2022 38a-591e(c)
410	410
411	411		INS Joint Favorable
412		-	APP Joint Favorable
413	412