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General Assembly Raised Bill No. 415
February Session, 2022
LCO No. 3074
Referred to Committee on INSURANCE AND REAL ESTATE
Introduced by:
(INS)
AN ACT CONCERNING STEP THERAPY, ADVERSE DETERMINATION
AND UTILIZATION REVIEWS.
Be it enacted by the Senate and House of Representatives in General
Assembly convened:
Section 1. Subsection (a) of 38a-510 of the general statutes is repealed 1
and the following is substituted in lieu thereof (Effective January 1, 2023): 2
(a) No insurance company, hospital service corporation, medical 3
service corporation, health care center or other entity delivering, issuing 4
for delivery, renewing, amending or continuing an individual health 5
insurance policy or contract that provides coverage for prescription 6
drugs may: 7
(1) Require any person covered under such policy or contract to 8
obtain prescription drugs from a mail order pharmacy as a condition of 9
obtaining benefits for such drugs; or 10
(2) Require, if such insurance company, hospital service corporation, 11
medical service corporation, health care center or other entity uses step 12
therapy for such drugs, the use of step therapy for: 13 Raised Bill No. 415
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(A) [any] Any prescribed drug for longer than sixty days; [,] or 14
(B) [a] A prescribed drug for [cancer] treatment of a behavioral health 15
condition or a chronic, disabling or life-threatening condition or disease 16
for an insured who has been diagnosed with [stage IV metastatic cancer] 17
such a condition or disease, provided such prescribed drug is in 18
compliance with approved federal Food and Drug Administration 19
indications. 20
(3) At the expiration of the time period specified in subparagraph (A) 21
of subdivision (2) of this subsection, [or for a prescribed drug described 22
in subparagraph (B) of subdivision (2) of this subsection,] an insured's 23
treating health care provider may deem such step therapy drug regimen 24
clinically ineffective for the insured, at which time the insurance 25
company, hospital service corporation, medical service corporation, 26
health care center or other entity shall authorize dispensation of and 27
coverage for the drug prescribed by the insured's treating health care 28
provider, provided such drug is a covered drug under such policy or 29
contract. If such provider does not deem such step therapy drug 30
regimen clinically ineffective or has not requested an override pursuant 31
to subdivision (1) of subsection (b) of this section, such drug regimen 32
may be continued. For purposes of this section, "step therapy" means a 33
protocol or program that establishes the specific sequence in which 34
prescription drugs for a specified medical condition are to be prescribed. 35
Sec. 2. Subsection (a) of section 38a-544 of the general statutes is 36
repealed and the following is substituted in lieu thereof (Effective January 37
1, 2023): 38
(a) No insurance company, hospital service corporation, medical 39
service corporation, health care center or other entity delivering, issuing 40
for delivery, renewing, amending or continuing a group health 41
insurance policy or contract that provides coverage for prescription 42
drugs may: 43
(1) Require any person covered under such policy or contract to 44
obtain prescription drugs from a mail order pharmacy as a condition of 45 Raised Bill No. 415
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obtaining benefits for such drugs; or 46
(2) Require, if such insurance company, hospital service corporation, 47
medical service corporation, health care center or other entity uses step 48
therapy for such drugs, the use of step therapy for: 49
(A) [any] Any prescribed drug for longer than sixty days; [,] or 50
(B) [a] A prescribed drug for [cancer] treatment of a behavioral health 51
condition or a chronic, disabling or life-threatening condition or disease 52
for an insured who has been diagnosed with [stage IV metastatic cancer] 53
such a condition or disease, provided such prescribed drug is in 54
compliance with approved federal Food and Drug Administration 55
indications. 56
(3) At the expiration of the time period specified in subparagraph (A) 57
of subdivision (2) of this subsection, [or for a prescribed drug described 58
in subparagraph (B) of subdivision (2) of this subsection,] an insured's 59
treating health care provider may deem such step therapy drug regimen 60
clinically ineffective for the insured, at which time the insurance 61
company, hospital service corporation, medical service corporation, 62
health care center or other entity shall authorize dispensation of and 63
coverage for the drug prescribed by the insured's treating health care 64
provider, provided such drug is a covered drug under such policy or 65
contract. If such provider does not deem such step therapy drug 66
regimen clinically ineffective or has not requested an override pursuant 67
to subdivision (1) of subsection (b) of this section, such drug regimen 68
may be continued. For purposes of this section, "step therapy" means a 69
protocol or program that establishes the specific sequence in which 70
prescription drugs for a specified medical condition are to be prescribed. 71
Sec. 3. Subdivision (7) of section 38a-591a of the general statutes is 72
repealed and the following is substituted in lieu thereof (Effective January 73
1, 2023): 74
(7) "Clinical peer" means a physician or other health care professional 75
who: 76 Raised Bill No. 415
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(A) [holds] For a review other than as specified under subparagraph 77
(B) or (C) of subdivision (38) of this section: 78
(i) Holds a nonrestricted license in a state of the United States [and] 79
in the same [or similar] specialty as [typically manages the medical 80
condition, procedure or treatment] the treating physician or other health 81
care professional under review; [, and] 82
(ii) Holds a doctoral or medical degree; and 83
(iii) (I) Holds an applicable national board certification including at 84
the subspecialty level, where available, or (II) actively practices and 85
typically manages the medical condition under review or provides the 86
procedure or treatment under review; or 87
(B) [for] For a review specified under subparagraph (B) or (C) of 88
subdivision (38) of this section concerning: 89
(i) [a] A child or adolescent substance use disorder or a child or 90
adolescent mental disorder, holds (I) a national board certification in 91
child and adolescent psychiatry, or (II) a doctoral level psychology 92
degree with training and clinical experience in the treatment of child 93
and adolescent substance use disorder or child and adolescent mental 94
disorder, as applicable; [,] or 95
(ii) [an] An adult substance use disorder or an adult mental disorder, 96
holds (I) a national board certification in psychiatry, or (II) a doctoral 97
level psychology degree with training and clinical experience in the 98
treatment of adult substance use disorders or adult mental disorders, as 99
applicable. 100
Sec. 4. Subsection (a) of section 38a-591c of the general statutes is 101
repealed and the following is substituted in lieu thereof (Effective January 102
1, 2023): 103
(a) (1) Each health carrier shall contract with (A) health care 104
professionals to administer such health carrier's utilization review 105
program, and (B) clinical peers to evaluate the clinical appropriateness 106 Raised Bill No. 415
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of an adverse determination. 107
(2) (A) Each utilization review program shall use documented clinical 108
review criteria that are based on sound clinical evidence and are 109
evaluated periodically by the health carrier's organizational mechanism 110
specified in subparagraph (F) of subdivision (2) of subsection (c) of 111
section 38a-591b to assure such program's ongoing effectiveness. 112
(B) Except as provided in subdivisions (3), (4) and (5) of this 113
subsection, a health carrier may develop its own clinical review criteria 114
or it may purchase or license clinical review criteria from qualified 115
vendors approved by the commissioner, provided such clinical review 116
criteria conform to the requirements of subparagraph (A) of this 117
subdivision. 118
(C) Each health carrier shall (i) post on its Internet web site (I) any 119
clinical review criteria it uses, and (II) links to any rule, guideline, 120
protocol or other similar criterion a health carrier may rely upon to make 121
an adverse determination as described in subparagraph (F) of 122
subdivision (1) of subsection (e) of section 38a-591d, as amended by this 123
act, and (ii) make its clinical review criteria available upon request to 124
authorized government agencies. 125
(D) For each utilization review, there shall be a rebuttable 126
presumption that each health care service under review is medically 127
necessary if such health care service was ordered by a health care 128
professional acting within the health care professional's scope of 129
practice. A health carrier, or any utilization review company or designee 130
of a health carrier that performs utilization review on behalf of the 131
health carrier, shall have the burden of proving that a health care service 132
is not medically necessary. 133
(3) For any utilization review for the treatment of a substance use 134
disorder, as described in section 17a-458, the clinical review criteria used 135
shall be: (A) The most recent edition of the American Society of 136
Addiction Medicine Treatment Criteria for Addictive, Substance-137
Related, and Co-Occurring Conditions; or (B) clinical review criteria that 138 Raised Bill No. 415
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the health carrier demonstrates to the Insurance Department is 139
consistent with the most recent edition of the American Society of 140
Addiction Medicine Treatment Criteria for Addictive, Substance-141
Related, and Co-Occurring Conditions, except that nothing in this 142
subdivision shall prohibit a health carrier from developing its own 143
clinical review criteria or purchasing or licensing additional clinical 144
review criteria from qualified vendors approved by the commissioner, 145
to address advancements in technology or types of care for the 146
treatment of a substance use disorder, that are not covered in the most 147
recent edition of the American Society of Addiction Medicine Treatment 148
Criteria for Addictive, Substance-Related, and Co-Occurring 149
Conditions. Any such clinical review criteria developed by a health 150
carrier or purchased or licensed from a qualified vendor shall conform 151
to the requirements of subparagraph (A) of subdivision (2) of this 152
subsection. 153
(4) For any utilization review for the treatment of a child or 154
adolescent mental disorder, the clinical review criteria used shall be: (A) 155
The most recent guidelines of the American Academy of Child and 156
Adolescent Psychiatry's Child and Adolescent Service Intensity 157
Instrument; or (B) clinical review criteria that the health carrier 158
demonstrates to the Insurance Department is consistent with the most 159
recent guidelines of the American Academy of Child and Adolescent 160
Psychiatry's Child and Adolescent Service Intensity Instrument, except 161
that nothing in this subdivision shall prohibit a health carrier from 162
developing its own clinical review criteria or purchasing or licensing 163
additional clinical review criteria from qualified vendors approved by 164
the commissioner, to address advancements in technology or types of 165
care for the treatment of a child or adolescent mental disorder, that are 166
not covered in the most recent guidelines of the American Academy of 167
Child and Adolescent Psychiatry's Child and Adolescent Service 168
Intensity Instrument. Any such clinical review criteria developed by a 169
health carrier or purchased or licensed from a qualified vendor shall 170
conform to the requirements of subparagraph (A) of subdivision (2) of 171
this subsection. 172 Raised Bill No. 415
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(5) For any utilization review for the treatment of an adult mental 173
disorder, the clinical review criteria used shall be: (A) The most recent 174
guidelines of the American Psychiatric Association or the most recent 175
Standards and Guidelines of the Association for Ambulatory Behavioral 176
Healthcare; or (B) clinical review criteria that the health carrier 177
demonstrates to the Insurance Department is consistent with the most 178
recent guidelines of the American Psychiatric Association or the most 179
recent Standards and Guidelines of the Association for Ambulatory 180
Behavioral Healthcare, except that nothing in this subdivision shall 181
prohibit a health carrier from developing its own clinical review criteria 182
or purchasing or licensing additional clinical review criteria from 183
qualified vendors approved by the commissioner, to address 184
advancements in technology or types of care for the treatment of an 185
adult mental disorder, that are not covered in the most recent guidelines 186
of the American Psychiatric Association or the most recent Standards 187
and Guidelines of the Association for Ambulatory Behavioral 188
Healthcare. Any such clinical review criteria developed by a health 189
carrier or purchased or licensed from a qualified vendor shall conform 190
to the requirements of subparagraph (A) of subdivision (2) of this 191
subsection. 192
Sec. 5. Subsection (a) of section 38a-591d of the general statutes is 193
repealed and the following is substituted in lieu thereof (Effective January 194
1, 2023): 195
(a) (1) Each health carrier shall maintain written procedures for (A) 196
utilization review and benefit determinations, (B) expedited utilization 197
review and benefit determinations with respect to prospective urgent 198
care requests and concurrent review urgent care requests, and (C) 199
notifying covered persons or covered persons' authorized 200
representatives of such review and benefit determinations. Each health 201
carrier shall make such review and benefit determinations within the 202
specified time periods under this section. 203
(2) In determining whether a benefit request shall be considered an 204
urgent care request, an individual acting on behalf of a health carrier 205 Raised Bill No. 415
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shall apply the judgment of a prudent layperson who possesses an 206
average knowledge of health and medicine, except that any benefit 207
request (A) determined to be an urgent care request by a health care 208
professional with knowledge of the covered person's medical condition, 209
or (B) specified under subparagraph (B) or (C) of subdivision (38) of 210
section 38a-591a, as amended by this act, shall be deemed an urgent care 211
request. 212
(3) (A) At the time a health carrier notifies a covered person, a covered 213
person's authorized representative or a covered person's health care 214
professional of an initial adverse determination that was based, in whole 215
or in part, on medical necessity, of a concurrent or prospective 216
utilization review or of a benefit request, the health carrier shall notify 217
the covered person's health care professional (i) of the opportunity for a 218
conference as provided in subparagraph (B) of this subdivision, and (ii) 219
that such conference shall not be considered a grievance of such initial 220
adverse determination as long as a grievance has not been filed as set 221
forth in subparagraph (B) of this subdivision. 222
(B) After a health carrier notifies a covered person, a covered person's 223
authorized representative or a covered person's health care professional 224
of an initial adverse determination that was based, in whole or in part, 225
on medical necessity, of a concurrent or prospective utilization review 226
or of a benefit request, the health carrier shall offer a covered person's 227
health care professional the opportunity to confer, at the request of the 228
covered person's health care professional, with a clinical peer of such 229
health carrier, provided such covered person, covered person's 230
authorized representative or covered person's health care professional 231
has not filed a grievance of such initial adverse determination prior to 232
such conference. Such conference shall not be considered a grievance of 233
such initial adverse determination. Such health carrier shall grant such 234
clinical peer authority to reverse such initial adverse determination. 235
Sec. 6. Subsection (c) of section 38a-591e of the general statutes is 236
repealed and the following is substituted in lieu thereof (Effective January 237
1, 2023): 238 Raised Bill No. 415
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(c) (1) (A) When conducting a review of an adverse determination 239
under this section, the health carrier shall ensure that such review is 240
conducted in a manner to ensure the independence and impartiality of 241
the clinical peer or peers involved in making the review decision. 242
(B) If the adverse determination involves utilization review, the 243
health carrier shall designate an appropriate clinical peer or peers to 244
review such adverse determination. Such clinical peer or peers shall not 245
have been involved in the initial adverse determination. 246
(C) (i) For each review of an adverse determination under this section, 247
there shall be a rebuttable presumption that each health care service 248
under review is medically necessary if such health care service was 249
ordered by a health care professional acting within the scope of the 250
health care professional's practice. The health carrier may rebut such 251
presumption by reasonably substantiating to the clinical peer or peers 252
conducting the review under this section that such health care service is 253
not medically necessary. 254
[(C)] (ii) The clinical peer or peers conducting a review under this 255
section shall take into consideration all comments, documents, records 256
and other information relevant to the covered person's benefit request 257
that is the subject of the adverse determination under review, that are 258
submitted by the covered person or the covered person's authorized 259
representative, regardless of whether such information was submitted 260
or considered in making the initial adverse determination. 261
(D) Prior to issuing a decision, the health carrier shall provide free of 262
charge, by facsimile, electronic means or any other expeditious method 263
available, to the covered person or the covered person's authorized 264
representative, as applicable, any new or additional documents, 265
communications, information and evidence relied upon and any new or 266
additional scientific or clinical rationale used by the health carrier in 267
connection with the grievance. Such documents, communications, 268
information, evidence and rationale shall be provided sufficiently in 269
advance of the date the health carrier is required to issue a decision to 270 Raised Bill No. 415
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permit the covered person or the covered person's authorized 271
representative, as applicable, a reasonable opportunity to respond prior 272
to such date. 273
(2) If the review under subdivision (1) of this subsection is an 274
expedited review, all necessary information, including the health 275
carrier's decision, shall be transmitted between the health carrier and the 276
covered person or the covered person's authorized representative, as 277
applicable, by telephone, facsimile, electronic means or any other 278
expeditious method available. 279
(3) If the review under subdivision (1) of this subsection is an 280
expedited review of a grievance involving an adverse determination of 281
a concurrent review request, pursuant to 45 CFR 147.136, as amended 282
from time to time, the treatment shall be continued without liability to 283
the covered person until the covered person has been notified of the 284
review decision. 285
This act shall take effect as follows and shall amend the following
sections:
Section 1 January 1, 2023 38a-510(a)
Sec. 2 January 1, 2023 38a-544(a)
Sec. 3 January 1, 2023 38a-591a(7)
Sec. 4 January 1, 2023 38a-591c(a)
Sec. 5 January 1, 2023 38a-591d(a)
Sec. 6 January 1, 2023 38a-591e(c)
Statement of Purpose:
To (1) 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; (2) redefine
"clinical peer" for the purposes of adverse determination and utilization
reviews; (3) require health carriers to bear the burden of proving that
certain health care services under adverse determination or utilization
review are not medically necessary; and (4) require health carriers to
provide certain clinical peers with authority to reverse initial adverse
determinations. Raised Bill No. 415
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[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.]