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General Assembly Raised Bill No. 416
February Session, 2022
LCO No. 3028
Referred to Committee on INSURANCE AND REAL ESTATE
Introduced by:
(INS)
AN ACT PROMOTING COMPETITION IN CONTRACTS BETWEEN
HEALTH CARRIERS AND HEALTH CARE PROVIDERS.
Be it enacted by the Senate and House of Representatives in General
Assembly convened:
Section 1. Section 38a-477g of the 2022 supplement to the general 1
statutes is repealed and the following is substituted in lieu thereof 2
(Effective January 1, 2023): 3
(a) As used in this section: 4
(1) "Anti-steering clause" means a provision of a health care contract 5
that restricts the ability of the health insurance carrier or health plan 6
administrator from encouraging an enrollee to obtain a health care 7
service from a competitor of the hospital or health system, including 8
offering incentives to encourage enrollees to utilize specific health care 9
providers. 10
(2) "Anti-tiering clause" means a provision in a health care contract 11
that: 12
(A) Restricts the ability of the health insurance carrier or health plan 13 Raised Bill No. 416
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administrator from introducing or modifying a tiered network plan or 14
assign health care providers into tiers; or 15
(B) Requires the health insurance carrier or health plan administrator 16
to place all members of a health care provider in the same tier of a tiered 17
network plan. 18
(3) "All-or-nothing clause" means a provision in a health care contract 19
that: 20
(A) Requires the health insurance carrier or health plan administrator 21
to include all members of a health care provider in a network plan; or 22
(B) Requires the health insurance carrier or health plan administrator 23
to enter into any additional contract with an affiliate of the health care 24
provider as a condition to entering into a contract with such health care 25
provider. 26
[(1)] (4) "Covered person", "facility" and "health carrier" have the 27
same meanings as provided in section 38a-591a. [,] 28
[(2) "health care provider"] (5) "Health care provider" has the same 29
meaning as provided in subsection (a) of section 38a-477aa. [, and] 30
(6) "Health plan administrator" means a third-party administrator 31
who acts on behalf of a plan sponsor to administer a health benefit plan. 32
[(3) "intermediary"] (7) "Intermediary", "network", "network plan" 33
and "participating provider" have the same meanings as provided in 34
subsection (a) of section 38a-472f. 35
(8) "Tiered network" has the same meaning as provided in section 36
38a-472f. 37
(b) (1) Each contract entered into, renewed or amended on or after 38
January 1, 2017, between a health carrier and a participating provider 39
shall include: 40
(A) A hold harmless provision that specifies protections for covered 41 Raised Bill No. 416
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persons. Such provision shall include the following statement or a 42
substantially similar statement: "Provider agrees that in no event, 43
including, but not limited to, nonpayment by the health carrier or 44
intermediary, the insolvency of the health carrier or intermediary, or a 45
breach of this agreement, shall the provider bill, charge, collect a deposit 46
from, seek compensation, remuneration or reimbursement from, or 47
have any recourse against a covered person or a person (other than the 48
health carrier or intermediary) acting on behalf of the covered person 49
for services provided pursuant to this agreement. This agreement does 50
not prohibit the provider from collecting coinsurance, deductibles or 51
copayments, as specifically provided in the evidence of coverage, or fees 52
for uncovered services delivered on a fee-for-service basis to covered 53
persons. Nor does this agreement prohibit a provider (except for a 54
health care provider who is employed full-time on the staff of a health 55
carrier and has agreed to provide services exclusively to that health 56
carrier's covered persons and no others) and a covered person from 57
agreeing to continue services solely at the expense of the covered 58
person, as long as the provider has clearly informed the covered person 59
that the health carrier does not cover or continue to cover a specific 60
service or services. Except as provided herein, this agreement does not 61
prohibit the provider from pursuing any available legal remedy."; 62
(B) A provision that in the event of a health carrier or intermediary 63
insolvency or other cessation of operations, the participating provider's 64
obligation to deliver covered health care services to covered persons 65
without requesting payment from a covered person other than a 66
coinsurance, copayment, deductible or other out-of-pocket expense for 67
such services will continue until the earlier of (i) the termination of the 68
covered person's coverage under the network plan, including any 69
extension of coverage provided under the contract terms or applicable 70
state or federal law for covered persons who are in an active course of 71
treatment, as set forth in subdivision (2) of subsection (g) of section 38a-72
472f, or are totally disabled, or (ii) the date the contract between the 73
health carrier and the participating provider would have terminated if 74
the health carrier or intermediary had remained in operation, including 75 Raised Bill No. 416
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any extension of coverage required under applicable state or federal law 76
for covered persons who are in an active course of treatment or are 77
totally disabled; 78
(C) (i) A provision that requires the participating provider to make 79
health records available to appropriate state and federal authorities 80
involved in assessing the quality of care provided to, or investigating 81
grievances or complaints of, covered persons, and (ii) a statement that 82
such participating provider shall comply with applicable state and 83
federal laws related to the confidentiality of medical and health records 84
and a covered person's right to view, obtain copies of or amend such 85
covered person's medical and health records; and 86
(D) (i) If such contract is entered into, renewed or amended before 87
July 1, 2022, definitions of what is considered timely notice and a 88
material change for the purposes of subparagraph (A) of subdivision (2) 89
of subsection (c) of this section, or (ii) if such contract is entered into, 90
renewed or amended on or after July 1, 2022, (I) a statement disclosing 91
the ninety-day advance written notice requirement established under 92
subparagraph (B) of subdivision (2) of subsection (c) of this section and 93
what is considered a material change for the purposes of subdivision (2) 94
of subsection (c) of this section, and (II) provisions affording the 95
participating provider a right to appeal any proposed change to the 96
provisions, other documents, provider manuals or policies disclosed 97
pursuant to subdivision (1) of subsection (c) of this section. 98
(2) The contract terms set forth in subparagraphs (A) and (B) of 99
subdivision (1) of this subsection shall (A) be construed in favor of the 100
covered person, (B) survive the termination of the contract regardless of 101
the reason for the termination, including the insolvency of the health 102
carrier, and (C) supersede any oral or written agreement between a 103
health care provider and a covered person or a covered person's 104
authorized representative that is contrary to or inconsistent with the 105
requirements set forth in subdivision (1) of this subsection. 106
(3) No contract subject to this subsection shall include any provision 107 Raised Bill No. 416
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that conflicts with the provisions contained in the network plan or 108
required under this section, section 38a-472f or section 38a-477h. 109
(4) No health carrier or participating provider that is a party to a 110
contract under this subsection shall assign or delegate any right or 111
responsibility required under such contract without the prior written 112
consent of the other party. 113
(c) (1) At the time a contract subject to subsection (b) of this section is 114
signed, the health carrier or such health carrier's intermediary shall 115
disclose to a participating provider: 116
(A) All provisions and other documents incorporated by reference in 117
such contract; and 118
(B) If such contract is entered into, renewed or amended on or after 119
July 1, 2022, all provider manuals and policies incorporated by reference 120
in such contract, if any. 121
(2) While such contract is in force, the health carrier shall: 122
(A) If such contract is entered into, renewed or amended before July 123
1, 2022, timely notify a participating provider of any change to the 124
provisions or other documents specified under subparagraph (A) of 125
subdivision (1) of this subsection that will result in a material change to 126
such contract; or 127
(B) If such contract is entered into, renewed or amended on or after 128
July 1, 2022, provide to a participating provider at least ninety days' 129
advance written notice of any change to the provisions or other 130
documents specified under subparagraph (A) of subdivision (1) of this 131
subsection, and any change to the provider manuals and policies 132
specified under subparagraph (B) of subdivision (1) of this subsection, 133
that will result in a material change to such contract or the procedures 134
that a participating provider must follow pursuant to such contract. 135
(d) (1) (A) Each contract between a health carrier and an intermediary 136
entered into, renewed or amended on or after January 1, 2017, shall 137 Raised Bill No. 416
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satisfy the requirements of this subsection. 138
(B) Each intermediary and participating providers with whom such 139
intermediary contracts shall comply with the applicable requirements 140
of this subsection. 141
(2) No health carrier shall assign or delegate to an intermediary such 142
health carrier's responsibilities to monitor the offering of covered 143
benefits to covered persons. To the extent a health carrier assigns or 144
delegates to an intermediary other responsibilities, such health carrier 145
shall retain full responsibility for such intermediary's compliance with 146
the requirements of this section. 147
(3) A health carrier shall have the right to approve or disapprove the 148
participation status of a health care provider or facility in such health 149
carrier's own or a contracted network that is subcontracted for the 150
purpose of providing covered benefits to the health carrier's covered 151
persons. 152
(4) A health carrier shall maintain at its principal place of business in 153
this state copies of all intermediary subcontracts or ensure that such 154
health carrier has access to all such subcontracts. Such health carrier 155
shall have the right, upon twenty days' prior written notice, to make 156
copies of any intermediary subcontracts to facilitate regulatory review. 157
(5) (A) Each intermediary shall, if applicable, (i) transmit to the health 158
carrier documentation of health care services utilization and claims 159
paid, and (ii) maintain at its principal place of business in this state, for 160
a period of time prescribed by the commissioner, the books, records, 161
financial information and documentation of health care services 162
received by covered persons, in a manner that facilitates regulatory 163
review, and shall allow the commissioner access to such books, records, 164
financial information and documentation as necessary for the 165
commissioner to determine compliance with this section and section 166
38a-472f. 167
(B) Each health carrier shall monitor the timeliness and 168 Raised Bill No. 416
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appropriateness of payments made by its intermediary to participating 169
providers and of health care services received by covered persons. 170
(6) In the event of the intermediary's insolvency, a health carrier shall 171
have the right to require the assignment to the health carrier of the 172
provisions of a participating provider's contract that address such 173
participating provider's obligation to provide covered benefits. If a 174
health carrier requires such assignment, such health carrier shall remain 175
obligated to pay the participating provider for providing covered 176
benefits under the same terms and conditions as the intermediary prior 177
to the insolvency. 178
(e) The commissioner shall not act to arbitrate, mediate or settle (1) 179
disputes regarding a health carrier's decision not to include a health care 180
provider or facility in such health carrier's network or network plan, or 181
(2) any other dispute between a health carrier, such health carrier's 182
intermediary or one or more participating providers, that arises under 183
or by reason of a participating provider contract or the termination of 184
such contract. 185
(f) No health insurance carrier, health care provider, health plan 186
administrator, or any agents or other entities that contract on behalf of 187
a health care provider, health insurance carrier or health plan 188
administrator may offer, solicit, request, amend, renew or enter into a 189
health care contract that would directly or indirectly include any of the 190
following provisions: 191
(1) An anti-steering clause; 192
(2) An anti-tiering clause; 193
(3) An all-or-nothing clause; or 194
(4) Any other clause that results or intends to result in 195
anticompetitive effects as may be adopted by the commissioner, in 196
accordance with chapter 54. 197
(g) Any contract, written policy, written procedure or agreement that 198 Raised Bill No. 416
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contains a clause contrary to the provisions set forth in subsection (f) of 199
this section shall be null and void. All remaining clauses of the contract 200
shall remain in effect for the duration of the contract term. 201
(h) The Insurance Commissioner may adopt regulations, in 202
accordance with chapter 54, to implement the provisions of subsection 203
(f) of this section. 204
This act shall take effect as follows and shall amend the following
sections:
Section 1 January 1, 2023 38a-477g
Statement of Purpose:
To exclude the following in contracts between health carriers and health
care providers: (1) Anti-steering clauses; anti-tiering clauses; and (2) all-
or-nothing clauses.
[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.]