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General Assembly Committee Bill No. 6
January Session, 2023
LCO No. 4966
Referred to Committee on INSURANCE AND REAL ESTATE
Introduced by:
(INS)
AN ACT CONCERNING UTILIZATION REVIEW AND HEALTH CARE
CONTRACTS, HEALTH INSURANCE COVERAGE FOR NEWBORNS
AND STEP THERAPY.
Be it enacted by the Senate and House of Representatives in General
Assembly convened:
Section 1. (NEW) (Effective October 1, 2023) (a) As used in this section: 1
(1) "Evaluation" means: 2
(A) With respect to a health care service or course of treatment for 3
which a participating provider does not have a prospective or 4
concurrent review exemption, a review by a health carrier of 5
prospective or concurrent review exemption requests submitted by such 6
participating provider during the most recent evaluation period to 7
determine the percentage of such requests that were approved, for a 8
health carrier to evaluate whether to grant or deny a prospective or 9
concurrent review exemption; or 10
(B) With respect to a health care service or course of treatment for 11
which a participating provider has a prospective or concurrent review 12
exemption, a retrospective review by a health carrier of a random 13 Committee Bill No. 6
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sample of payable claims submitted by such participating provider 14
during the most recent evaluation period to determine the percentage 15
of claims that would have been approved, based on meeting such health 16
carrier's applicable medical necessity criteria at the time the service was 17
provided, for such health carrier to evaluate whether to continue or 18
rescind a prospective or concurrent review exemption; and 19
(2) "Evaluation period" means the six-month period preceding an 20
evaluation. "Evaluation period" includes: 21
(A) For an initial determination of a prospective or concurrent review 22
exemption grant or denial for any health care service or course of 23
treatment, any six-month period that begins on January 1, 2024, July 1, 24
2024, or any subsequent six-month period that begins on any January 25
first or July first of any subsequent year; 26
(B) After a denial or rescission of a prospective or concurrent review 27
exemption for any health care service or course of treatment, the six-28
month period that commences on the first day following the end of the 29
evaluation period that formed the basis of such denial or rescission of a 30
prospective or concurrent review exemption; and 31
(C) For a notification of a prospective or concurrent review 32
exemption rescission, the six-month period after the health carrier 33
provided such notice of rescission to the participating provider or the 34
next six-month period, provided there shall not be more than two 35
months between the end of such evaluation period and the date such 36
notice is received by such participating provider. 37
(b) For any health care contract entered into, renewed or amended on 38
or after January 1, 2024, no health carrier that provides or performs 39
utilization review, including prospective and concurrent review, for any 40
health care service or course of treatment shall require that any 41
participating provider obtain prospective or concurrent review for any 42
health care service or course of treatment if, in the immediately 43
preceding six-month evaluation period, such health carrier approved 44 Committee Bill No. 6
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not less than ninety per cent of such prospective or concurrent review 45
requests submitted by such participating provider for such health care 46
service or course of treatment. 47
(c) Except for any exemption from the prospective or concurrent 48
review requirements that shall continue without evaluation pursuant to 49
subsection (f) of this section, each health carrier shall conduct an 50
evaluation once every six months to determine whether each 51
participating provider qualifies for an exemption from the prospective 52
or concurrent review requirements pursuant to subsection (b) of this 53
section. 54
(d) No participating provider shall be required to request an 55
exemption from such prospective or concurrent review requirements in 56
order to qualify for such exemption. 57
(e) Each participating provider's exemption from the prospective or 58
concurrent review requirements pursuant to subsection (b) of this 59
section, shall remain in effect until: 60
(1) The thirtieth day after the date on which the health carrier notifies 61
such participating provider of such health carrier's determination to 62
rescind such exemption pursuant to the provisions of subsection (g) of 63
this section, provided such participating provider does not appeal such 64
health carrier's determination in accordance with the provisions of 65
subsection (i) of this section; or 66
(2) If such participating provider appeals such health carrier's 67
determination in accordance with the provisions of subsection (i) of this 68
section and the independent review organization affirms such health 69
carrier's determination to rescind such exemption, the fifth day after the 70
date such independent review organization affirms such health carrier's 71
determination to rescind such exemption. 72
(f) If a health carrier does not finalize any determination to rescind 73
such exemption from the prospective or concurrent review 74
requirements in accordance with the provisions of subsection (e) of this 75 Committee Bill No. 6
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section, the participating provider shall automatically satisfy the 76
exemption from the prospective or concurrent review requirements 77
pursuant to subsection (b) of this section. 78
(g) Each health carrier may rescind any participating provider 79
exemption from the prospective or concurrent review requirements 80
under subsection (b) of this section only: 81
(1) During January or July of each year; 82
(2) If such health carrier makes a determination on the basis of a 83
retrospective review of a random sample of not less than five and not 84
more than twenty claims submitted by such participating provider 85
during the most recent evaluation period, as set forth in subsection (b) 86
of this section, that less than ninety per cent of such claims for the health 87
care service or course of treatment met the medical necessity criteria that 88
would have been used by such health carrier when conducting 89
prospective or concurrent review for the health care service or course of 90
treatment during the relevant evaluation period; and 91
(3) If such health carrier: 92
(A) Notifies such participating provider, in writing, not less than 93
thirty days before such rescission is to take effect; and 94
(B) Provides with such notice pursuant to subparagraph (A) of this 95
subdivision: 96
(i) The sample information used by such health carrier to make such 97
determination pursuant to subdivision (2) of this subsection; and 98
(ii) A plain language description identifying the process for such 99
participating provider to (I) submit an appeal of such rescission, and (II) 100
seek an independent review of such determination. 101
(h) No health carrier may deny an exemption from the prospective or 102
concurrent review requirements set forth in subsection (b) of this 103 Committee Bill No. 6
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section, unless such health carrier provides the participating provider 104
with statistics and data for the relevant prospective or concurrent 105
review evaluation period and information sufficient to demonstrate that 106
such participating provider fails to meet the criteria for an exemption 107
from the prospective or concurrent review requirements set forth in 108
subsection (b) of this section for each health care service or course of 109
treatment. 110
(i) (1) If a health carrier rescinds any participating provider's 111
exemption from the prospective or concurrent review requirements 112
pursuant to subsection (g) of this section, such participating provider 113
may request an independent review of such health carrier's 114
determination. Such independent review shall be conducted by an 115
independent review organization. No health carrier shall require a 116
participating provider to engage in an internal review process before 117
requesting an independent review of an adverse determination of an 118
exemption. 119
(2) Each health carrier that issues any adverse determination of a 120
participating provider's exemption pursuant to subsection (g) of this 121
section that is the subject of such independent review shall pay: 122
(A) The independent review organization for the cost of conducting 123
such independent review requested by such participating provider 124
pursuant to subdivision (1) of this subsection; and 125
(B) Reasonable fees for copies of all documents, communications, 126
information and evidence relating to the adverse determination of such 127
participating provider's exemption requested by such participating 128
provider for purposes of such independent review pursuant to this 129
subsection. The Insurance Commissioner shall adopt regulations, in 130
accordance with the provisions of chapter 54 of the general statutes, to 131
implement such fees that shall be paid by health carriers pursuant to 132
this subparagraph. 133
(3) Each independent review organization shall complete the review 134 Committee Bill No. 6
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of any adverse determination of the participating provider's exemption 135
not later than the thirtieth calendar day after the date that such 136
participating provider files such request for such independent review 137
under subdivision (1) of this subsection. 138
(4) The participating provider may request that the independent 139
review organization consider a random sample of not less than five and 140
not more than twenty claims submitted to the health carrier by such 141
participating provider during the relevant evaluation period for the 142
health care service or course of treatment that is subject to such 143
independent review as part of such independent review organization's 144
review. If such participating provider requests a review of such random 145
sample, such independent review organization shall base its 146
determination on the medical necessity of claims reviewed by such 147
health carrier under subdivision (2) of subsection (g) of this section and 148
by such independent review organization pursuant to this subdivision. 149
(j) (1) Each independent review determination shall be binding on the 150
health carrier and the participating provider, except to the extent such 151
health carrier or participating provider has other remedies available 152
under federal or state law. 153
(2) No health carrier shall retroactively deny any health care service 154
or course of treatment on the basis of a rescission of an exemption, even 155
if such health carrier's determination to rescind such prospective or 156
concurrent review exemption is affirmed by an independent review 157
organization. 158
(3) If any independent review organization overturns any health 159
carrier's determination of a prospective or concurrent review 160
exemption, such health carrier: 161
(A) Shall not attempt to rescind such exemption before the end of the 162
next evaluation period; and 163
(B) May only rescind such exemption after the end of the next 164
evaluation period, provided such health carrier complies with the 165 Committee Bill No. 6
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provisions of subsections (g) to (i), inclusive, of this section. 166
(k) After a final determination or review affirming a rescission or 167
denial of an exemption for a health care service or course of treatment, 168
any participating provider shall be eligible for reconsideration of such 169
exemption for the same health care service or course of treatment after 170
the end of the six-month evaluation period that follows such evaluation 171
period that formed the basis of the rescission or denial of such 172
exemption. 173
(l) (1) No health carrier shall deny or reduce payment to a 174
participating provider for any health care service or course of treatment 175
for which such participating provider has qualified for an exemption 176
from the prospective or concurrent review requirements pursuant to 177
subsection (b) of this section based on medical necessity or 178
appropriateness of care, unless such participating provider: 179
(A) Knowingly and materially misrepresented such health care 180
service or course of treatment in a request for payment submitted to 181
such health carrier; or 182
(B) Failed to substantially perform such health care service or course 183
of treatment. 184
(2) No health carrier shall conduct a retrospective review of any 185
health care service or course of treatment subject to an exemption 186
pursuant to subsection (b) of this section, except: 187
(A) To determine if a participating provider qualifies for such 188
exemption under subsection (b) of this section; or 189
(B) If such health carrier has reasonable cause to believe that a basis 190
for denial exists under subdivision (1) of this subsection. 191
(3) Not later than five business days after any participating provider 192
qualifies for an exemption from the prospective or concurrent review 193
requirements under subsection (b) of this section, the health carrier shall 194 Committee Bill No. 6
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provide to such participating provider a written notice that includes: 195
(A) A statement that such participating provider qualifies for an 196
exemption from the prospective or concurrent review requirements; 197
(B) A list of such participating provider's health care services or 198
course of treatments, and health benefit plans to which such exemption 199
applies; and 200
(C) A statement identifying the duration of such exemption. 201
(4) If a participating provider submits a prospective or concurrent 202
review request to a health carrier for any health care service or course of 203
treatment for which such participating provider qualifies for an 204
exemption from the prospective or concurrent review requirements 205
pursuant to subsection (b) of this section, such health carrier shall 206
promptly provide written notice to such participating provider that 207
includes: 208
(A) The information required under subparagraphs (A) to (C), 209
inclusive, of subdivision (3) of this subsection; and 210
(B) Notification of such health carrier's payment requirements. 211
(m) The commissioner shall adopt regulations, in accordance with the 212
provisions of chapter 54 of the general statutes, to carry out the 213
provisions of this section. 214
Sec. 2. Section 38a-591c of the general statutes is repealed and the 215
following is substituted in lieu thereof (Effective October 1, 2023): 216
(a) (1) Each health carrier shall contract with (A) health care 217
professionals to administer such health carrier's utilization review 218
program, and (B) clinical peers to evaluate the clinical appropriateness 219
of an adverse determination. 220
(2) (A) Each utilization review program shall use documented clinical 221
review criteria that are based on sound clinical evidence and are 222 Committee Bill No. 6
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evaluated periodically by the health carrier's organizational mechanism 223
specified in subparagraph (F) of subdivision (2) of subsection (c) of 224
section 38a-591b to assure such program's ongoing effectiveness. 225
(B) Except as provided in subdivisions (3), (4) and (5) of this 226
subsection, a health carrier may develop its own clinical review criteria 227
or it may purchase or license clinical review criteria from qualified 228
vendors approved by the commissioner, provided such clinical review 229
criteria conform to the requirements of subparagraph (A) of this 230
subdivision. 231
(C) Each health carrier shall (i) post on its Internet web site (I) any 232
clinical review criteria it uses, and (II) links to any rule, guideline, 233
protocol or other similar criterion a health carrier may rely upon to make 234
an adverse determination as described in subparagraph (F) of 235
subdivision (1) of subsection (e) of section 38a-591d, as amended by this 236
act, and (ii) make its clinical review criteria available upon request to 237
authorized government agencies. 238
(3) For any utilization review for the treatment of a substance use 239
disorder, as described in section 17a-458, the clinical review criteria used 240
shall be: (A) The most recent edition of the American Society of 241
Addiction Medicine Treatment Criteria for Addictive, Substance-242
Related, and Co-Occurring Conditions; or (B) clinical review criteria that 243
the health carrier demonstrates to the Insurance Department is 244
consistent with the most recent edition of the American Society of 245
Addiction Medicine Treatment Criteria for Addictive, Substance-246
Related, and Co-Occurring Conditions, except that nothing in this 247
subdivision shall prohibit a health carrier from developing its own 248
clinical review criteria or purchasing or licensing additional clinical 249
review criteria from qualified vendors approved by the commissioner, 250
to address advancements in technology or types of care for the 251
treatment of a substance use disorder, that are not covered in the most 252
recent edition of the American Society of Addiction Medicine Treatment 253
Criteria for Addictive, Substance-Related, and Co-Occurring 254
Conditions. Any such clinical review criteria developed by a health 255 Committee Bill No. 6
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carrier or purchased or licensed from a qualified vendor shall conform 256
to the requirements of subparagraph (A) of subdivision (2) of this 257
subsection. 258
(4) For any utilization review for the treatment of a child or 259
adolescent mental disorder, the clinical review criteria used shall be: (A) 260
The most recent guidelines of the American Academy of Child and 261
Adolescent Psychiatry's Child and Adolescent Service Intensity 262
Instrument; or (B) clinical review criteria that the health carrier 263
demonstrates to the Insurance Department is consistent with the most 264
recent guidelines of the American Academy of Child and Adolescent 265
Psychiatry's Child and Adolescent Service Intensity Instrument, except 266
that nothing in this subdivision shall prohibit a health carrier from 267
developing its own clinical review criteria or purchasing or licensing 268
additional clinical review criteria from qualified vendors approved by 269
the commissioner, to address advancements in technology or types of 270
care for the treatment of a child or adolescent mental disorder, that are 271
not covered in the most recent guidelines of the American Academy of 272
Child and Adolescent Psychiatry's Child and Adolescent Service 273
Intensity Instrument. Any such clinical review criteria developed by a 274
health carrier or purchased or licensed from a qualified vendor shall 275
conform to the requirements of subparagraph (A) of subdivision (2) of 276
this subsection. 277
(5) For any utilization review for the treatment of an adult mental 278
disorder, the clinical review criteria used shall be: (A) The most recent 279
guidelines of the American Psychiatric Association or the most recent 280
Standards and Guidelines of the Association for Ambulatory Behavioral 281
Healthcare; or (B) clinical review criteria that the health carrier 282
demonstrates to the Insurance Department is consistent with the most 283
recent guidelines of the American Psychiatric Association or the most 284
recent Standards and Guidelines of the Association for Ambulatory 285
Behavioral Healthcare, except that nothing in this subdivision shall 286
prohibit a health carrier from developing its own clinical review criteria 287
or purchasing or licensing additional clinical review criteria from 288 Committee Bill No. 6
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qualified vendors approved by the commissioner, to address 289
advancements in technology or types of care for the treatment of an 290
adult mental disorder, that are not covered in the most recent guidelines 291
of the American Psychiatric Association or the most recent Standards 292
and Guidelines of the Association for Ambulatory Behavioral 293
Healthcare. Any such clinical review criteria developed by a health 294
carrier or purchased or licensed from a qualified vendor shall conform 295
to the requirements of subparagraph (A) of subdivision (2) of this 296
subsection. 297
(b) Each health carrier shall: 298
(1) Have procedures in place to ensure that (A) the health care 299
professionals administering such health carrier's utilization review 300
program are applying the clinical review criteria consistently in 301
utilization review determinations, and (B) the appropriate or required 302
individual or individuals are being designated to conduct utilization 303
reviews; 304
(2) Have data systems sufficient to support utilization review 305
program activities and to generate management reports to enable the 306
health carrier to monitor and manage health care services effectively; 307
(3) Provide covered persons and participating providers with access 308
to its utilization review staff through a toll-free telephone number or 309
any other free calling option or by electronic means; 310
(4) Coordinate the utilization review program with other medical 311
management activity conducted by the health carrier, such as quality 312
assurance, credentialing, contracting with health care professionals, 313
data reporting, grievance procedures, processes for assessing member 314
satisfaction and risk management; and 315
(5) Routinely assess the effectiveness and efficiency of its utilization 316
review program. 317
(c) If a health carrier delegates any utilization review activities to a 318 Committee Bill No. 6
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utilization review company, the health carrier shall maintain adequate 319
oversight, which shall include (1) a written description of the utilization 320
review company's activities and responsibilities, including such 321
company's reporting requirements, (2) evidence of the health carrier's 322
formal approval of the utilization review company program, and (3) a 323
process by which the health carrier shall evaluate the utilization review 324
company's performance. 325
(d) When conducting utilization review, the health carrier shall (1) 326
collect only the information necessary, including pertinent clinical 327
information, to make the utilization review or benefit determination, 328
and (2) ensure that such review is conducted in a manner to ensure the 329
independence and impartiality of the individual or individuals involved 330
in making the utilization review or benefit determination. No health 331
carrier shall make decisions regarding the hiring, compensation, 332
termination, promotion or other similar matters of such individual or 333
individuals based on the likelihood that the individual or individuals 334
will support the denial of benefits. 335
(e) Not later than January 1, 2024, each health carrier shall establish 336
an electronic program to provide for the secure electronic: 337
(1) Filing of prospective and concurrent review requests, and other 338
requests for prospective or concurrent utilization reviews, by hospital 339
and health care professionals with such health carrier, and submission 340
of available clinical information in support of such requests; and 341
(2) Transmission of such health carrier's responses to such requests 342
described in subdivision (1) of this subsection. 343
Sec. 3. Section 38a-591d of the general statutes is repealed and the 344
following is substituted in lieu thereof (Effective October 1, 2023): 345
(a) (1) Each health carrier shall maintain written procedures for (A) 346
utilization review and benefit determinations, (B) expedited utilization 347
review and benefit determinations with respect to prospective urgent 348
care requests and concurrent review urgent care requests, and (C) 349 Committee Bill No. 6
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notifying covered persons or covered persons' authorized 350
representatives of such review and benefit determinations. Each health 351
carrier shall make such review and benefit determinations within the 352
specified time periods under this section. 353
(2) In determining whether a benefit request shall be considered an 354
urgent care request, an individual acting on behalf of a health carrier 355
shall apply the judgment of a prudent layperson who possesses an 356
average knowledge of health and medicine, except that any benefit 357
request (A) determined to be an urgent care request by a health care 358
professional with knowledge of the covered person's medical condition, 359
or (B) specified under subparagraph (B) or (C) of subdivision (38) of 360
section 38a-591a shall be deemed an urgent care request. 361
(3) (A) At the time a health carrier notifies a covered person, a covered 362
person's authorized representative or a covered person's health care 363
professional of an initial adverse determination that was based, in whole 364
or in part, on medical necessity, of a concurrent or prospective 365
utilization review or of a benefit request, the health carrier shall notify 366
the covered person's health care professional (i) of the opportunity for a 367
conference as provided in subparagraph (B) of this subdivision, and (ii) 368
that such conference shall not be considered a grievance of such initial 369
adverse determination as long as a grievance has not been filed as set 370
forth in subparagraph (B) of this subdivision. 371
(B) After a health carrier notifies a covered person, a covered person's 372
authorized representative or a covered person's health care professional 373
of an initial adverse determination that was based, in whole or in part, 374
on medical necessity, of a concurrent or prospective utilization review 375
or of a benefit request, the health carrier shall offer a covered person's 376
health care professional the opportunity to confer, at the request of the 377
covered person's health care professional, with a clinical peer of such 378
health carrier, provided such covered person, covered person's 379
authorized representative or covered person's health care professional 380
has not filed a grievance of such initial adverse determination prior to 381
such conference. Such conference shall not be considered a grievance of 382 Committee Bill No. 6
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such initial adverse determination. 383
(b) With respect to a nonurgent care request: 384
(1) (A) For a prospective or concurrent review request, a health carrier 385
shall make a determination within a reasonable period of time 386
appropriate to the covered person's medical condition, but not later than 387
[fifteen calendar days] seventy-two hours after the date the health 388
carrier receives such request, and shall notify the covered person and, if 389
applicable, the covered person's authorized representative of such 390
determination, whether or not the carrier certifies the provision of the 391
benefit. 392
(B) If the review under subparagraph (A) of this subdivision is a 393
review of a grievance involving a concurrent review request, pursuant 394
to 45 CFR 147.136, as amended from time to time, the treatment shall be 395
continued without liability to the covered person until the covered 396
person has been notified of the review decision. 397
(2) For a retrospective review request, a health carrier shall make a 398
determination within a reasonable period of time, but not later than 399
thirty calendar days after the date the health carrier receives such 400
request. 401
(3) The time periods specified in subdivisions (1) and (2) of this 402
subsection may be extended once by the health carrier for up to [fifteen 403
calendar days] seventy-two hours, provided the health carrier: 404
(A) Determines that an extension is necessary due to circumstances 405
beyond the health carrier's control; and 406
(B) Notifies the covered person and, if applicable, the covered 407
person's authorized representative prior to the expiration of the initial 408
time period, of the circumstances requiring the extension of time and 409
the date by which the health carrier expects to make a determination. 410
(4) (A) If the extension pursuant to subdivision (3) of this subsection 411 Committee Bill No. 6
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is necessary due to the failure of the covered person or the covered 412
person's authorized representative to provide information necessary to 413
make a determination on the request, the health carrier shall: 414
(i) Specifically describe in the notice of extension the required 415
information necessary to complete the request; and 416
(ii) Provide the covered person and, if applicable, the covered 417
person's authorized representative with not less than forty-five calendar 418
days after the date of receipt of the notice to provide the specified 419
information. 420
(B) If the covered person or the covered person's authorized 421
representative fails to submit the specified information before the end 422
of the period of the extension, the health carrier may deny certification 423
of the benefit requested. 424
(c) With respect to an urgent care request: 425
(1) (A) Unless the covered person or the covered person's authorized 426
representative has failed to provide information necessary for the health 427
carrier to make a determination and except as specified under 428
subparagraph (B) of this subdivision, the health carrier shall make a 429
determination as soon as possible, taking into account the covered 430
person's medical condition, but not later than [forty-eight] twenty-four 431
hours after the health carrier receives such request, [or seventy-two 432
hours after such health carrier receives such request if any portion of 433
such forty-eight-hour period falls on a weekend,] provided, if the urgent 434
care request is a concurrent review request to extend a course of 435
treatment beyond the initial period of time or the number of treatments, 436
such request is made [at least] not less than twenty-four hours prior to 437
the expiration of the prescribed period of time or number of treatments. 438
(B) Unless the covered person or the covered person's authorized 439
representative has failed to provide information necessary for the health 440
carrier to make a determination, for an urgent care request specified 441
under subparagraph (B) or (C) of subdivision (38) of section 38a-591a, 442 Committee Bill No. 6
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the health carrier shall make a determination as soon as possible, taking 443
into account the covered person's medical condition, but not later than 444
twenty-four hours after the health carrier receives such request, 445
provided, if the urgent care request is a concurrent review request to 446
extend a course of treatment beyond the initial period of time or the 447
number of treatments, such request is made [at least] not less than 448
twenty-four hours prior to the expiration of the prescribed period of 449
time or number of treatments. 450
(2) (A) If the covered person or the covered person's authorized 451
representative has failed to provide information necessary for the health 452
carrier to make a determination, the health carrier shall notify the 453
covered person or the covered person's representative, as applicable, as 454
soon as possible, but not later than twenty-four hours after the health 455
carrier receives such request. 456
(B) The health carrier shall provide the covered person or the covered 457
person's authorized representative, as applicable, a reasonable period of 458
time to submit the specified information, taking into account the 459
covered person's medical condition, but not less than forty-eight hours 460
after notifying the covered person or the covered person's authorized 461
representative, as applicable. 462
(3) The health carrier shall notify the covered person and, if 463
applicable, the covered person's authorized representative of its 464
determination as soon as possible, but not later than forty-eight hours 465
after the earlier of (A) the date on which the covered person and the 466
covered person's authorized representative, as applicable, provides the 467
specified information to the health carrier, or (B) the date on which the 468
specified information was to have been submitted. 469
(d) (1) [Whenever a health carrier receives a review request from a 470
covered person or a covered person's authorized representative that 471
fails to meet the health carrier's filing procedures, the health carrier shall 472
notify the covered person and, if applicable, the covered person's 473
authorized representative of such failure not later than five calendar 474 Committee Bill No. 6
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days after the health carrier receives such request, except that for an 475
urgent care request, the health carrier shall notify the covered person 476
and, if applicable, the covered person's authorized representative of 477
such failure not later than twenty-four hours after the health carrier 478
receives such request.] With respect to prospective and concurrent 479
review requests, each health carrier shall: 480
(A) Process prospective and concurrent review requests twenty-four 481
hours a day, seven days a week, including holidays; and 482
(B) Acknowledge receipt of each nonurgent prospective and 483
concurrent review request as soon as practicable, but not later than 484
twenty-four hours following such health carrier's receipt of such 485
prospective and concurrent review request, except that such health 486
carrier shall respond in less time if such a response is required by 487
applicable federal law. 488
(2) [If the health carrier provides such notice orally, the health carrier 489
shall provide confirmation in writing to the covered person and the 490
covered person's health care professional of record not later than five 491
calendar days after providing the oral notice] No health carrier shall 492
require a health care professional or hospital to submit additional 493
information that was not reasonably available to such health care 494
professional or hospital at the time that such health care professional or 495
hospital filed the prospective or concurrent review request with such 496
health carrier. 497
(e) Each health carrier shall provide promptly to a covered person 498
and, if applicable, the covered person's authorized representative a 499
notice of an adverse determination. 500
(1) Such notice may be provided in writing or by electronic means 501
and shall set forth, in a manner calculated to be understood by the 502
covered person or the covered person's authorized representative: 503
(A) Information sufficient to identify the benefit request or claim 504
involved, including the date of service, if applicable, the health care 505 Committee Bill No. 6
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professional and the claim amount; 506
(B) The specific reason or reasons for the adverse determination, 507
including, upon request, a listing of the relevant clinical review criteria, 508
including professional criteria and medical or scientific evidence and a 509
description of the health carrier's standard, if any, that were used in 510
reaching the denial; 511
(C) Reference to the specific health benefit plan provisions on which 512
the determination is based; 513
(D) A description of any additional material or information necessary 514
for the covered person to perfect the benefit request or claim, including 515
an explanation of why the material or information is necessary to perfect 516
the request or claim; 517
(E) A description of the health carrier's internal grievance process that 518
includes (i) the health carrier's expedited review procedures, (ii) any 519
time limits applicable to such process or procedures, (iii) the contact 520
information for the organizational unit designated to coordinate the 521
review on behalf of the health carrier, and (iv) a statement that the 522
covered person or, if applicable, the covered person's authorized 523
representative is entitled, pursuant to the requirements of the health 524
carrier's internal grievance process, to receive from the health carrier, 525
free of charge upon request, reasonable access to and copies of all 526
documents, records, communications and other information and 527
evidence regarding the covered person's benefit request; 528
(F) (i) (I) A copy of the specific rule, guideline, protocol or other 529
similar criterion the health carrier relied upon to make the adverse 530
determination, or (II) a statement that a specific rule, guideline, protocol 531
or other similar criterion of the health carrier was relied upon to make 532
the adverse determination and that a copy of such rule, guideline, 533
protocol or other similar criterion will be provided to the covered person 534
free of charge upon request, with instructions for requesting such copy, 535
and (ii) the links to such rule, guideline, protocol or other similar 536 Committee Bill No. 6
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criterion on such health carrier's Internet web site; 537
(G) If the adverse determination is based on medical necessity or an 538
experimental or investigational treatment or similar exclusion or limit, 539
the written statement of the scientific or clinical rationale for the adverse 540
determination and (i) an explanation of the scientific or clinical rationale 541
used to make the determination that applies the terms of the health 542
benefit plan to the covered person's medical circumstances or (ii) a 543
statement that an explanation will be provided to the covered person 544
free of charge upon request, and instructions for requesting a copy of 545
such explanation; 546
(H) A statement explaining the right of the covered person to contact 547
the commissioner's office or the Office of the Healthcare Advocate at 548
any time for assistance or, upon completion of the health carrier's 549
internal grievance process, to file a civil action in a court of competent 550
jurisdiction. Such statement shall include the contact information for 551
said offices; and 552
(I) A statement, expressed in language approved by the Healthcare 553
Advocate and prominently displayed on the first page or cover sheet of 554
the notice using a call-out box and large or bold text, that if the covered 555
person or the covered person's authorized representative chooses to file 556
a grievance of an adverse determination, (i) such appeals are sometimes 557
successful, (ii) such covered person or covered person's authorized 558
representative may benefit from free assistance from the Office of the 559
Healthcare Advocate, which can assist such covered person or covered 560
person's authorized representative with the filing of a grievance 561
pursuant to 42 USC 300gg-93, as amended from time to time, (iii) such 562
covered person or covered person's authorized representative is entitled 563
and encouraged to submit supporting documentation for the health 564
carrier's consideration during the review of an adverse determination, 565
including narratives from such covered person or covered person's 566
authorized representative and letters and treatment notes from such 567
covered person's health care professional, and (iv) such covered person 568
or covered person's authorized representative has the right to ask such 569 Committee Bill No. 6
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covered person's health care professional for such letters or treatment 570
notes. 571
(2) Upon request pursuant to subparagraph (E) of subdivision (1) of 572
this subsection, the health carrier shall provide such copies in 573
accordance with subsection (a) of section 38a-591n. 574
(f) If the adverse determination is a rescission, the health carrier shall 575
include with the advance notice of the application for rescission 576
required to be sent to the covered person, a written statement that 577
includes: 578
(1) Clear identification of the alleged fraudulent act, practice or 579
omission or the intentional misrepresentation of material fact; 580
(2) An explanation as to why the act, practice or omission was 581
fraudulent or was an intentional misrepresentation of a material fact; 582
(3) A disclosure that the covered person or the covered person's 583
authorized representative may file immediately, without waiting for the 584
date such advance notice of the proposed rescission ends, a grievance 585
with the health carrier to request a review of the adverse determination 586
to rescind coverage, pursuant to sections 38a-591e and 38a-591f; 587
(4) A description of the health carrier's grievance procedures 588
established under sections 38a-591e and 38a-591f, including any time 589
limits applicable to those procedures; and 590
(5) The date such advance notice of the proposed rescission ends and 591
the date back to which the coverage will be retroactively rescinded. 592
(g) (1) Whenever a health carrier fails to strictly adhere to the 593
requirements of this section with respect to making utilization review 594
and benefit determinations of a benefit request or claim, the covered 595
person shall be deemed to have exhausted the internal grievance 596
process of such health carrier and may file a request for an external 597
review in accordance with the provisions of section 38a-591g, regardless 598 Committee Bill No. 6
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of whether the health carrier asserts it substantially complied with the 599
requirements of this section or that any error it committed was de 600
minimis. 601
(2) A covered person who has exhausted the internal grievance 602
process of a health carrier may, in addition to filing a request for an 603
external review, pursue any available remedies under state or federal 604
law on the basis that the health carrier failed to provide a reasonable 605
internal grievance process that would yield a decision on the merits of 606
the claim. 607
Sec. 4. Section 38a-490 of the general statutes is repealed and the 608
following is substituted in lieu thereof (Effective October 1, 2023): 609
(a) Each individual health insurance policy delivered, issued for 610
delivery, renewed, amended or continued in this state providing 611
coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) 612
and (12) of section 38a-469 for a family member of the insured or 613
subscriber shall, as to such family member's coverage, also provide that 614
the health insurance benefits applicable for children shall be payable 615
with respect to a newly born child of the insured or subscriber from the 616
moment of birth. 617
(b) Coverage for such newly born child shall consist of coverage for 618
injury and sickness including necessary care and treatment of medically 619
diagnosed congenital defects and birth abnormalities within the limits 620
of the policy. 621
(c) If payment of a specific premium or subscription fee is required to 622
provide coverage for a child, the policy or contract may require that 623
notification of birth of such newly born child and payment of the 624
required premium or fees shall be furnished to the insurer, hospital 625
service corporation, medical service corporation or health care center 626
not later than [sixty-one] one hundred twenty-one days after the date of 627
birth or the date of discharge from the hospital, whichever is later, in 628
order to continue coverage beyond such [sixty-one-day] period, 629 Committee Bill No. 6
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provided failure to furnish such notice or pay such premium or fees 630
shall not prejudice any claim originating within such [sixty-one-day] 631
period. 632
Sec. 5. Section 38a-516 of the general statutes is repealed and the 633
following is substituted in lieu thereof (Effective October 1, 2023): 634
(a) Each group health insurance policy delivered, issued for delivery, 635
renewed, amended or continued in this state providing coverage of the 636
type specified in subdivisions (1), (2), (4), (6), (11) and (12) of section 38a-637
469 for a family member of the insured or subscriber shall, as to such 638
family member's coverage, also provide that the health insurance 639
benefits applicable for children shall be payable with respect to a newly 640
born child of the insured or subscriber from the moment of birth. 641
(b) Coverage for such newly born child shall consist of coverage for 642
injury and sickness including necessary care and treatment of medically 643
diagnosed congenital defects and birth abnormalities within the limits 644
of the policy. 645
(c) If payment of a specific premium fee is required to provide 646
coverage for a child, the policy may require that notification of birth of 647
such newly born child and payment of the required premium or fees 648
shall be furnished to the insurer, hospital service corporation, medical 649
service corporation or health care center not later than [sixty-one] one 650
hundred twenty-one days after the date of birth or the date of discharge 651
from the hospital, whichever is later, in order to continue coverage 652
beyond such [sixty-one-day] period, provided failure to furnish such 653
notice or pay such premium shall not prejudice any claim originating 654
within such [sixty-one-day] period. 655
Sec. 6. Subsection (a) of section 38a-510 of the general statutes is 656
repealed and the following is substituted in lieu thereof (Effective October 657
1, 2023): 658
(a) No insurance company, hospital service corporation, medical 659
service corporation, health care center or other entity delivering, issuing 660 Committee Bill No. 6
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for delivery, renewing, amending or continuing an individual health 661
insurance policy or contract that provides coverage for prescription 662
drugs may: 663
(1) Require any person covered under such policy or contract to 664
obtain prescription drugs from a mail order pharmacy as a condition of 665
obtaining benefits for such drugs; or 666
(2) Require, if such insurance company, hospital service corporation, 667
medical service corporation, health care center or other entity uses step 668
therapy for such drugs, the use of step therapy for: 669
(A) [any] Any prescribed drug for longer than sixty days; [,] or 670
(B) [a] A prescribed drug for [cancer] treatment of a behavioral health 671
condition or a chronic, disabling or life-threatening condition or disease 672
for an insured who has been diagnosed with [stage IV metastatic cancer] 673
such a condition or disease, provided such prescribed drug is in 674
compliance with approved federal Food and Drug Administration 675
indications. 676
(3) At the expiration of the time period specified in subparagraph (A) 677
of subdivision (2) of this subsection, [or for a prescribed drug described 678
in subparagraph (B) of subdivision (2) of this subsection,] an insured's 679
treating health care provider may deem such step therapy drug regimen 680
clinically ineffective for the insured, at which time the insurance 681
company, hospital service corporation, medical service corporation, 682
health care center or other entity shall authorize dispensation of and 683
coverage for the drug prescribed by the insured's treating health care 684
provider, provided such drug is a covered drug under such policy or 685
contract. If such provider does not deem such step therapy drug 686
regimen clinically ineffective or has not requested an override pursuant 687
to subdivision (1) of subsection (b) of this section, such drug regimen 688
may be continued. For purposes of this section, "step therapy" means a 689
protocol or program that establishes the specific sequence in which 690
prescription drugs for a specified medical condition are to be prescribed. 691 Committee Bill No. 6
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Sec. 7. Subsection (a) of section 38a-544 of the general statutes is 692
repealed and the following is substituted in lieu thereof (Effective October 693
1, 2023): 694
(a) No insurance company, hospital service corporation, medical 695
service corporation, health care center or other entity delivering, issuing 696
for delivery, renewing, amending or continuing a group health 697
insurance policy or contract that provides coverage for prescription 698
drugs may: 699
(1) Require any person covered under such policy or contract to 700
obtain prescription drugs from a mail order pharmacy as a condition of 701
obtaining benefits for such drugs; or 702
(2) Require, if such insurance company, hospital service corporation, 703
medical service corporation, health care center or other entity uses step 704
therapy for such drugs, the use of step therapy for: 705
(A) [any] Any prescribed drug for longer than sixty days; [,] or 706
(B) [a] A prescribed drug for [cancer] treatment of a behavioral health 707
condition or a chronic, disabling or life-threatening condition or disease 708
for an insured who has been diagnosed with [stage IV metastatic cancer] 709
such a condition or disease, provided such prescribed drug is in 710
compliance with approved federal Food and Drug Administration 711
indications. 712
(3) At the expiration of the time period specified in subparagraph (A) 713
of subdivision (2) of this subsection, [or for a prescribed drug described 714
in subparagraph (B) of subdivision (2) of this subsection,] an insured's 715
treating health care provider may deem such step therapy drug regimen 716
clinically ineffective for the insured, at which time the insurance 717
company, hospital service corporation, medical service corporation, 718
health care center or other entity shall authorize dispensation of and 719
coverage for the drug prescribed by the insured's treating health care 720
provider, provided such drug is a covered drug under such policy or 721
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regimen clinically ineffective or has not requested an override pursuant 723
to subdivision (1) of subsection (b) of this section, such drug regimen 724
may be continued. For purposes of this section, "step therapy" means a 725
protocol or program that establishes the specific sequence in which 726
prescription drugs for a specified medical condition are to be prescribed. 727
Sec. 8. (NEW) (Effective October 1, 2023) No health carrier shall require 728
a prospective or concurrent review of a recurring health care service or 729
prescription drug after such health carrier has certified such health care 730
service or prescription drug through utilization review. Nothing in this 731
section shall require a health carrier to cover any health care service or 732
prescription drug for a health condition of which the terms of coverage 733
completely exclude such health care service or prescription drug from 734
the policy's covered benefits. 735
This act shall take effect as follows and shall amend the following
sections:
Section 1 October 1, 2023 New section
Sec. 2 October 1, 2023 38a-591c
Sec. 3 October 1, 2023 38a-591d
Sec. 4 October 1, 2023 38a-490
Sec. 5 October 1, 2023 38a-516
Sec. 6 October 1, 2023 38a-510(a)
Sec. 7 October 1, 2023 38a-544(a)
Sec. 8 October 1, 2023 New section
INS Joint Favorable
APP Joint Favorable