Connecticut 2022 Regular Session

Connecticut Senate Bill SB00416 Compare Versions

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7		-	General Assembly Substitute Bill No. 416
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8	7		February Session, 2022
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	10	+
	11	+	Referred to Committee on INSURANCE AND REAL ESTATE
	12	+
	13	+
	14	+	Introduced by:
	15	+	(INS)
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12	20		AN ACT PROMOTING COMPETITION IN CONTRACTS BETWEEN
13	21		HEALTH CARRIERS AND HEALTH CARE PROVIDERS.
14	22		Be it enacted by the Senate and House of Representatives in General
15	23		Assembly convened:
16	24
17	25		Section 1. Section 38a-477g of the 2022 supplement to the general 1
18	26		statutes is repealed and the following is substituted in lieu thereof 2
19	27		(Effective January 1, 2023): 3
20	28		(a) As used in this section: 4
21		-	(1) "All-or-nothing clause" means a provision in a health care contract 5
22		-	that: 6
23		-	(A) Requires the health insurance carrier or health plan administrator 7
24		-	to include all members of a health care provider in a network plan; or 8
25		-	(B) Requires the health insurance carrier or health plan administrator 9
26		-	to enter into any additional contract with an affiliate of the health care 10
27		-	provider as a condition to entering into a contract with such health care 11
28		-	provider. 12
29		-	(2) "Anti-steering clause" means a provision of a health care contract 13
30		-	that restricts the ability of the health insurance carrier or health plan 14
31		-	administrator from encouraging an enrollee to obtain a health care 15
32		-	service from a competitor of the hospital or health system, including 16
33		-	offering incentives to encourage enrollees to utilize specific health care 17 Substitute Bill No. 416
	29	+	(1) "Anti-steering clause" means a provision of a health care contract 5
	30	+	that restricts the ability of the health insurance carrier or health plan 6
	31	+	administrator from encouraging an enrollee to obtain a health care 7
	32	+	service from a competitor of the hospital or health system, including 8
	33	+	offering incentives to encourage enrollees to utilize specific health care 9
	34	+	providers. 10
	35	+	(2) "Anti-tiering clause" means a provision in a health care contract 11
	36	+	that: 12
	37	+	(A) Restricts the ability of the health insurance carrier or health plan 13 Raised Bill No. 416
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40		-	providers. 18
41		-	(3) "Anti-tiering clause" means a provision in a health care contract 19
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	43	+	administrator from introducing or modifying a tiered network plan or 14
	44	+	assign health care providers into tiers; or 15
	45	+	(B) Requires the health insurance carrier or health plan administrator 16
	46	+	to place all members of a health care provider in the same tier of a tiered 17
	47	+	network plan. 18
	48	+	(3) "All-or-nothing clause" means a provision in a health care contract 19
42	49		that: 20
43		-	(A) ~~Restricts the ability of~~ the health insurance carrier or health plan 21
44		-	~~administrator~~ to ~~introduce and modify~~ a ~~tiered~~ network plan or ~~assign~~ 22
45		-	health ~~care providers into tiers;~~ or 23
46		-	~~(B) Requires~~ the health ~~insurance carrier or health plan administrator~~ 24
47		-	to ~~place all members of~~ a health care ~~provider in the same tier of a tiered~~ 25
48		-	~~network plan~~. 26
	50	+	(A) Requires the health insurance carrier or health plan administrator 21
	51	+	to include all members of a health care provider in a network plan; or 22
	52	+	(B) Requires the health insurance carrier or health plan administrator 23
	53	+	to enter into any additional contract with an affiliate of the health care 24
	54	+	provider as a condition to entering into a contract with such health care 25
	55	+	provider. 26
49	56		[(1)] (4) "Covered person", "facility" and "health carrier" have the 27
50	57		same meanings as provided in section 38a-591a. [,] 28
51	58		[(2) "health care provider"] (5) "Health care provider" has the same 29
52	59		meaning as provided in subsection (a) of section 38a-477aa. [, and] 30
53	60		(6) "Health plan administrator" means a third-party administrator 31
54	61		who acts on behalf of a plan sponsor to administer a health benefit plan. 32
55	62		[(3) "intermediary"] (7) "Intermediary", "network", "network plan" 33
56	63		and "participating provider" have the same meanings as provided in 34
57	64		subsection (a) of section 38a-472f. 35
58	65		(8) "Tiered network" has the same meaning as provided in section 36
59	66		38a-472f. 37
60	67		(b) (1) Each contract entered into, renewed or amended on or after 38
61	68		January 1, 2017, between a health carrier and a participating provider 39
62	69		shall include: 40
63		-	(A) A hold harmless provision that specifies protections for covered 41
	70	+	(A) A hold harmless provision that specifies protections for covered 41 Raised Bill No. 416
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64	76		persons. Such provision shall include the following statement or a 42
65	77		substantially similar statement: "Provider agrees that in no event, 43
66	78		including, but not limited to, nonpayment by the health carrier or 44
67		-	intermediary, the insolvency of the health carrier or intermediary, or a 45 Substitute Bill No. 416
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	79	+	intermediary, the insolvency of the health carrier or intermediary, or a 45
74	80		breach of this agreement, shall the provider bill, charge, collect a deposit 46
75	81		from, seek compensation, remuneration or reimbursement from, or 47
76	82		have any recourse against a covered person or a person (other than the 48
77	83		health carrier or intermediary) acting on behalf of the covered person 49
78	84		for services provided pursuant to this agreement. This agreement does 50
79	85		not prohibit the provider from collecting coinsurance, deductibles or 51
80	86		copayments, as specifically provided in the evidence of coverage, or fees 52
81	87		for uncovered services delivered on a fee-for-service basis to covered 53
82	88		persons. Nor does this agreement prohibit a provider (except for a 54
83	89		health care provider who is employed full-time on the staff of a health 55
84	90		carrier and has agreed to provide services exclusively to that health 56
85	91		carrier's covered persons and no others) and a covered person from 57
86	92		agreeing to continue services solely at the expense of the covered 58
87	93		person, as long as the provider has clearly informed the covered person 59
88	94		that the health carrier does not cover or continue to cover a specific 60
89	95		service or services. Except as provided herein, this agreement does not 61
90	96		prohibit the provider from pursuing any available legal remedy."; 62
91	97		(B) A provision that in the event of a health carrier or intermediary 63
92	98		insolvency or other cessation of operations, the participating provider's 64
93	99		obligation to deliver covered health care services to covered persons 65
94	100		without requesting payment from a covered person other than a 66
95	101		coinsurance, copayment, deductible or other out-of-pocket expense for 67
96	102		such services will continue until the earlier of (i) the termination of the 68
97	103		covered person's coverage under the network plan, including any 69
98	104		extension of coverage provided under the contract terms or applicable 70
99	105		state or federal law for covered persons who are in an active course of 71
100	106		treatment, as set forth in subdivision (2) of subsection (g) of section 38a-72
101	107		472f, or are totally disabled, or (ii) the date the contract between the 73
102	108		health carrier and the participating provider would have terminated if 74
103		-	the health carrier or intermediary had remained in operation, including 75
	109	+	the health carrier or intermediary had remained in operation, including 75 Raised Bill No. 416
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104	115		any extension of coverage required under applicable state or federal law 76
105	116		for covered persons who are in an active course of treatment or are 77
106		-	totally disabled; 78 Substitute Bill No. 416
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	117	+	totally disabled; 78
113	118		(C) (i) A provision that requires the participating provider to make 79
114	119		health records available to appropriate state and federal authorities 80
115	120		involved in assessing the quality of care provided to, or investigating 81
116	121		grievances or complaints of, covered persons, and (ii) a statement that 82
117	122		such participating provider shall comply with applicable state and 83
118	123		federal laws related to the confidentiality of medical and health records 84
119	124		and a covered person's right to view, obtain copies of or amend such 85
120	125		covered person's medical and health records; and 86
121	126		(D) (i) If such contract is entered into, renewed or amended before 87
122	127		July 1, 2022, definitions of what is considered timely notice and a 88
123	128		material change for the purposes of subparagraph (A) of subdivision (2) 89
124	129		of subsection (c) of this section, or (ii) if such contract is entered into, 90
125	130		renewed or amended on or after July 1, 2022, (I) a statement disclosing 91
126	131		the ninety-day advance written notice requirement established under 92
127	132		subparagraph (B) of subdivision (2) of subsection (c) of this section and 93
128	133		what is considered a material change for the purposes of subdivision (2) 94
129	134		of subsection (c) of this section, and (II) provisions affording the 95
130	135		participating provider a right to appeal any proposed change to the 96
131	136		provisions, other documents, provider manuals or policies disclosed 97
132	137		pursuant to subdivision (1) of subsection (c) of this section. 98
133	138		(2) The contract terms set forth in subparagraphs (A) and (B) of 99
134	139		subdivision (1) of this subsection shall (A) be construed in favor of the 100
135	140		covered person, (B) survive the termination of the contract regardless of 101
136	141		the reason for the termination, including the insolvency of the health 102
137	142		carrier, and (C) supersede any oral or written agreement between a 103
138	143		health care provider and a covered person or a covered person's 104
139	144		authorized representative that is contrary to or inconsistent with the 105
140	145		requirements set forth in subdivision (1) of this subsection. 106
141		-	(3) No contract subject to this subsection shall include any provision 107
	146	+	(3) No contract subject to this subsection shall include any provision 107 Raised Bill No. 416
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142	152		that conflicts with the provisions contained in the network plan or 108
143	153		required under this section, section 38a-472f or section 38a-477h. 109
144		-	(4) No health carrier or participating provider that is a party to a 110 Substitute Bill No. 416
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	154	+	(4) No health carrier or participating provider that is a party to a 110
151	155		contract under this subsection shall assign or delegate any right or 111
152	156		responsibility required under such contract without the prior written 112
153	157		consent of the other party. 113
154	158		(c) (1) At the time a contract subject to subsection (b) of this section is 114
155	159		signed, the health carrier or such health carrier's intermediary shall 115
156	160		disclose to a participating provider: 116
157	161		(A) All provisions and other documents incorporated by reference in 117
158	162		such contract; and 118
159	163		(B) If such contract is entered into, renewed or amended on or after 119
160	164		July 1, 2022, all provider manuals and policies incorporated by reference 120
161	165		in such contract, if any. 121
162	166		(2) While such contract is in force, the health carrier shall: 122
163	167		(A) If such contract is entered into, renewed or amended before July 123
164	168		1, 2022, timely notify a participating provider of any change to the 124
165	169		provisions or other documents specified under subparagraph (A) of 125
166	170		subdivision (1) of this subsection that will result in a material change to 126
167	171		such contract; or 127
168	172		(B) If such contract is entered into, renewed or amended on or after 128
169	173		July 1, 2022, provide to a participating provider at least ninety days' 129
170	174		advance written notice of any change to the provisions or other 130
171	175		documents specified under subparagraph (A) of subdivision (1) of this 131
172	176		subsection, and any change to the provider manuals and policies 132
173	177		specified under subparagraph (B) of subdivision (1) of this subsection, 133
174	178		that will result in a material change to such contract or the procedures 134
175	179		that a participating provider must follow pursuant to such contract. 135
176	180		(d) (1) (A) Each contract between a health carrier and an intermediary 136
177		-	entered into, renewed or amended on or after January 1, 2017, shall 137
178		-	satisfy the requirements of this subsection. 138
179		-	(B) Each intermediary and participating providers with whom such 139 Substitute Bill No. 416
	181	+	entered into, renewed or amended on or after January 1, 2017, shall 137 Raised Bill No. 416
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	187	+	satisfy the requirements of this subsection. 138
	188	+	(B) Each intermediary and participating providers with whom such 139
186	189		intermediary contracts shall comply with the applicable requirements 140
187	190		of this subsection. 141
188	191		(2) No health carrier shall assign or delegate to an intermediary such 142
189	192		health carrier's responsibilities to monitor the offering of covered 143
190	193		benefits to covered persons. To the extent a health carrier assigns or 144
191	194		delegates to an intermediary other responsibilities, such health carrier 145
192	195		shall retain full responsibility for such intermediary's compliance with 146
193	196		the requirements of this section. 147
194	197		(3) A health carrier shall have the right to approve or disapprove the 148
195	198		participation status of a health care provider or facility in such health 149
196	199		carrier's own or a contracted network that is subcontracted for the 150
197	200		purpose of providing covered benefits to the health carrier's covered 151
198	201		persons. 152
199	202		(4) A health carrier shall maintain at its principal place of business in 153
200	203		this state copies of all intermediary subcontracts or ensure that such 154
201	204		health carrier has access to all such subcontracts. Such health carrier 155
202	205		shall have the right, upon twenty days' prior written notice, to make 156
203	206		copies of any intermediary subcontracts to facilitate regulatory review. 157
204	207		(5) (A) Each intermediary shall, if applicable, (i) transmit to the health 158
205	208		carrier documentation of health care services utilization and claims 159
206	209		paid, and (ii) maintain at its principal place of business in this state, for 160
207	210		a period of time prescribed by the commissioner, the books, records, 161
208	211		financial information and documentation of health care services 162
209	212		received by covered persons, in a manner that facilitates regulatory 163
210	213		review, and shall allow the commissioner access to such books, records, 164
211	214		financial information and documentation as necessary for the 165
212	215		commissioner to determine compliance with this section and section 166
213	216		38a-472f. 167
214		-	(B) Each health carrier shall monitor the timeliness and 168
215		-	appropriateness of payments made by its intermediary to participating 169
216		-	providers and of health care services received by covered persons. 170 Substitute Bill No. 416
	217	+	(B) Each health carrier shall monitor the timeliness and 168 Raised Bill No. 416
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	223	+	appropriateness of payments made by its intermediary to participating 169
	224	+	providers and of health care services received by covered persons. 170
223	225		(6) In the event of the intermediary's insolvency, a health carrier shall 171
224	226		have the right to require the assignment to the health carrier of the 172
225	227		provisions of a participating provider's contract that address such 173
226	228		participating provider's obligation to provide covered benefits. If a 174
227	229		health carrier requires such assignment, such health carrier shall remain 175
228	230		obligated to pay the participating provider for providing covered 176
229	231		benefits under the same terms and conditions as the intermediary prior 177
230	232		to the insolvency. 178
231	233		(e) The commissioner shall not act to arbitrate, mediate or settle (1) 179
232	234		disputes regarding a health carrier's decision not to include a health care 180
233	235		provider or facility in such health carrier's network or network plan, or 181
234	236		(2) any other dispute between a health carrier, such health carrier's 182
235	237		intermediary or one or more participating providers, that arises under 183
236	238		or by reason of a participating provider contract or the termination of 184
237	239		such contract. 185
238	240		(f) No health insurance carrier, health care provider, health plan 186
239	241		administrator, or any agents or other entities that contract on behalf of 187
240	242		a health care provider, health insurance carrier or health plan 188
241	243		administrator may offer, solicit, request, amend, renew or enter into a 189
242	244		health care contract that would directly or indirectly include any of the 190
243	245		following provisions: 191
244		-	(1) An ~~all-or-nothing~~ clause; 192
245		-	(2) An anti-~~steering~~ clause; 193
246		-	(3) An ~~anti-tiering~~ clause; or 194
	246	+	(1) An anti-steering clause; 192
	247	+	(2) An anti-tiering clause; 193
	248	+	(3) An all-or-nothing clause; or 194
247	249		(4) Any other clause that results or intends to result in 195
248	250		anticompetitive effects as may be adopted by the commissioner, in 196
249	251		accordance with chapter 54. 197
250		-	(g) Any contract, written policy, written procedure or agreement that 198
251		-	contains a clause contrary to the provisions set forth in subsection (f) of 199
252		-	this section shall be null and void. All remaining clauses of the contract 200 Substitute Bill No. 416
	252	+	(g) Any contract, written policy, written procedure or agreement that 198 Raised Bill No. 416
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	258	+	contains a clause contrary to the provisions set forth in subsection (f) of 199
	259	+	this section shall be null and void. All remaining clauses of the contract 200
259	260		shall remain in effect for the duration of the contract term. 201
260	261		(h) The Insurance Commissioner may adopt regulations, in 202
261	262		accordance with chapter 54, to implement the provisions of subsection 203
262	263		(f) of this section. 204
263	264		This act shall take effect as follows and shall amend the following
264	265		sections:
265	266
266	267		Section 1 January 1, 2023 38a-477g
267	268
268		-	Statement of Legislative Commissioners:
269		-	Subsecs. (a)(1), (a)(2), (a)(3) and Subsecs. (f)(1), (f)(2) and (f)(3) were
270		-	reorganized alphabetically to comply with standard drafting
271		-	conventions; and in Subsec. (a)(3)(A), "from introducing or modifying"
272		-	was changed to "to introduce and modify" for clarity.
273		-
274		-	INS Joint Favorable Subst. -LCO
275		-
	269	+	Statement of Purpose:
	270	+	To exclude the following in contracts between health carriers and health
	271	+	care providers: (1) Anti-steering clauses; anti-tiering clauses; and (2) all-
	272	+	or-nothing clauses.
	273	+	[Proposed deletions are enclosed in brackets. Proposed additions are indicated by underline, except
	274	+	that when the entire text of a bill or resolution or a section of a bill or resolution is new, it is not
	275	+	underlined.]