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OLR Bill Analysis
SB 6 (File 337, as amended by Senate "A" and "B")*
AN ACT CONCERNING UTILIZATION REVIEW AND HEALTH CARE
CONTRACTS, HEALTH INSURANCE COVERAGE FOR NEWBORNS
AND STEP THERAPY.
SUMMARY
This bill makes the following changes to the insurance statutes:
1. prohibits health carriers (e.g., insurers and HMOs) from
requiring a prospective or concurrent review of a recurring
prescription drug used to treat an autoimmune disorder,
multiple sclerosis, or cancer that they already approved through
utilization review (§§ 1 & 2);
2. shortens the maximum timeframes for health carriers to notify an
insured or his or her authorized representative of certain
utilization reviews (§ 3);
3. extends, from 61 days to 91 days after birth, the time period
within which an insured person must (a) notify the insurer,
HMO, or hospital or medical service corporation about a
newborn’s birth and (b) pay any required premium or
subscription fee to continue the newborn’s coverage beyond that
period (§§ 4 & 5);
4. reduces how long an insurer can require an insured to use step
therapy for prescription drugs from 60 to 30 days and prohibits
step therapy from January 1, 2024, to January 1, 2027, for drugs
used to treat schizophrenia, major depressive disorder or bipolar
disorder (§§ 6 & 7);
5. establishes a 23-member task force to study step therapy data
collection, including step therapy edits, rejections, and appeals
for behavioral health drugs, and the best ways to collect data (§ 2023SB-00006-R01-BA.DOCX
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8);
6. requires managed care organizations (MCOs) to annually report
certain prior authorization and utilization review data, actuarial
analyses, and estimated premium savings to the insurance
commissioner, and requires the commissioner to include some of
this information in his annual consumer report card (§§ 9 & 10);
and
7. requires providers participating in a health carrier’s network to
use a carrier’s secure electronic system to process utilization
reviews (§ 11).
The bill also makes numerous minor and technical changes.
*Senate Amendment “A” (1) eliminates provisions that establish
conditions under which health carriers must exempt providers from
certain utilization reviews based on their approval rates for health care
services and treatments over the prior six months; (2) limits a
prohibition on reviews of recurring prescription drugs to those drugs
used to treat certain conditions; (3) shortens the underlying bill’s
extended time period to notify a carrier about a newborn’s birth from
121 to 91 days; (4) prohibits step therapy for a three-year period for
drugs used to treat schizophrenia, major depressive disorder or bipolar
disorder, rather than for behavioral health conditions or disabling,
chronic, or life-threatening conditions; (5) eliminates provisions
requiring health carriers to implement electronic utilization review
programs; (6) adds the step therapy task force, MCO reporting,
consumer report card, and electronic utilization review provisions; and
(7) makes numerous minor changes.
*Senate Amendment “B” delays by one year, until January 1, 2025,
the effective date of the provision prohibiting certain utilization reviews
of recurring prescription drugs to treat specified illnesses.
EFFECTIVE DATE: January 1, 2024, except (1) a technical section and
the provisions on MCO reporting and the consumer report card are
effective October 1, 2023; (2) the prohibition on utilization reviews for 2023SB-00006-R01-BA.DOCX
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certain reoccurring prescription drugs is effective January 1, 2025; and
(3) the step therapy task force is effective upon passage.
§§ 1 & 2 — PROHIBITION ON RE VIEWS OF RECURRING
PRESCRIPTION DRUGS TO TREAT AUTOIMMUNE DISORDERS,
MULTIPLE SCLEROSIS, OR CANCER
The bill prohibits health carriers from requiring a prospective or
concurrent review of a recurring prescription drug used to treat any
autoimmune disorder, multiple sclerosis, or cancer, after they have
certified it through utilization review. The bill specifies that it does not
require a health carrier to cover a (1) prescription drug to treat these
conditions if the policy’s coverage terms completely exclude the drug
from its covered benefits or (2) brand name drug if an equivalent generic
is available.
§ 3 — UTILIZATION REVIEW REQUEST TIME FRAMES
Existing law establishes a structure and timeframe for health carriers,
and any designee or utilization review company that performs
utilization reviews on their behalf, to conduct benefit reviews and notify
a covered individual whether a specific medical service is reimbursable
by his or her health insurance plan.
The bill shortens several of the maximum timeframes these entities
can take, after receiving all the required information, to notify an
insured or the insured’s authorized representative of decisions.
Specifically, the bill shortens the maximum response time for decisions
about the following requests:
1. a non-urgent prospective or concurrent review request, from 15
to 7 calendar days after the date the health carrier receives the
request, but the bill allows the health carrier to extend this once
for up to 15 days as long as the insured’s provider notifies the
carrier that the service will not be performed for at least three
months from the date the request was received;
2. a one-time extension of non-urgent prospective or concurrent
review request due to circumstances beyond the carrier’s control 2023SB-00006-R01-BA.DOCX
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and following proper notice, from 15 to 5 calendar days (for
retrospective reviews, the bill maintains current law’s one-time
extension of 15 calendar days); and
3. urgent care requests, from 48 hours (or 72 hours if the request or
response time falls on a weekend) to 24 hours after the health
carrier receives the request.
By law, urgent review requests must be done as soon as possible,
taking into account the insured’s medical condition.
Procedural Failures
The bill also changes how a health carrier must process review
requests that fail to meet the carrier’s filing procedures. Under current
law, a health carrier must notify an insured and his or her authorized
representative, if applicable, within five calendar days of receiving the
request for a non-urgent request or within 24 hours for an urgent care
request. Under the bill, for non-urgent prospective and concurrent
review requests, a carrier must instead acknowledge receipt of these
requests as soon as practicable but within 24 hours after receiving it,
unless federal law requires a faster response.
Current law allows health carriers to notify patients orally if it
provides written confirmation within five calendar days after providing
the oral notice. The bill shortens this time period to three calendar days.
Additionally, the bill prohibits health carriers from requiring that
health care professionals or hospitals submit additional information
with a prospective or concurrent review that is not reasonably available
to the provider or hospital at the time the request is submitted.
§§ 4 & 5 — NEWBORN HEALTH INSURANCE COVE RAGE
By law, certain health insurance policies that cover family members
must cover newborns from birth. The coverage must include injury and
sickness benefits, including the care and treatment of congenital defects
and birth abnormalities.
The bill extends, from 61 days after birth to 91 days after the birth, the 2023SB-00006-R01-BA.DOCX
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time period within which the insured person must (1) notify the insurer,
HMO, or hospital or medical service corporation about the birth and (2)
pay any required premium or subscription fee to continue the
newborn’s coverage beyond that period. As under current law, if
notification and payment is not provided within the specified period,
claims originating during that period are not prejudiced.
Under current law, these provisions apply to individual health
insurance policies that cover limited benefits and individual and group
health insurance policies delivered, issued, renewed, amended, or
continued in Connecticut that cover (1) basic hospital expenses; (2) basic
medical-surgical expenses; (3) major medical expenses; (4) accidents; or
(5) hospital or medical services, including those provided under an
HMO plan. The bill excludes individual and group accident only
policies from these provisions. (In practice, these policies are unlikely to
cover birth related services.)
Because of the federal Employee Retirement Income Security Act,
state insurance benefit mandates do not apply to self-insured benefit
plans.
§§ 6 & 7 — STEP THERAPY PROHIBITIONS
Step therapy is a protocol for establishing the sequence for
prescribing drugs for specific medical conditions that generally requires
patients to try less expensive drugs before higher cost drugs. The bill
lowers, from 60 to 30 days, the maximum amount of time an insurer can
require an insured use step therapy. (However, it does not make a
conforming change to a provision on requesting an authorization to
override any step therapy regimen.)
For the three-year period beginning January 1, 2024, the bill prohibits
step therapy for drugs used to treat schizophrenia, major depressive
disorder, or bipolar disorder, as defined in the American Psychiatric
Association’s “Diagnostic and Statistical Manual of Mental Disorders”
most recent edition. Additionally, the bill allows a health care provider
treating an insured with these conditions to deem step therapy clinically
ineffective. (Presumably, this applies following the three year 2023SB-00006-R01-BA.DOCX
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prohibition). At that point, the insurer must authorize dispensation of
and coverage for the drug prescribed by the provider, if it is covered
under the insurance policy or contract. If the provider does not consider
the step therapy regimen to be ineffective or does not request an
override as the law allows, the drug regimen may be continued.
Existing law, unchanged by the bill, prohibits step therapy use for
drugs used to treat stage IV metastatic cancer, as long as the drugs
comply with approved federal Food and Drug Administration
indications.
§ 8 — STEP THERAPY TASK FO RCE
Under the bill, the task force includes the following members:
1. two health care providers with mental health expertise, one each
appointed by the House speaker and the Senate president pro
tempore;
2. one licensed pharmacist, appointed by the House minority
leader;
3. one pharmaceutical manufacturing industry representative,
appointed by the Senate minority leader;
4. the chairpersons and ranking members of the Insurance and Real
Estate and Public Health committees, or their designees;
5. the Office of Health Strategy executive director, or her designee;
6. the insurance and consumer protection commissioners, or their
designees;
7. two insurance industry representatives, one each appointed by
the Insurance and Real Estate Committee chairpersons;
8. two pharmaceutical industry representatives, one each
appointed by the Insurance and Real Estate Committee’s ranking
members; 2023SB-00006-R01-BA.DOCX
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9. two mental health care providers, one each appointed by the
Public Health Committee’s chairpersons; and
10. two mental health advocacy group representatives, who must be
impacted individuals, appointed by the Public Health
Committee’s ranking members.
Appointing authorities must make their appointments within 30 days
after the bill’s passage and fill any vacancies. The House speaker and
Senate president pro tempore must select the task force’s chairpersons
from among its members. The chairpersons must schedule the first
meeting, which must be held within 60 days after the bill’s passage. The
Public Health Committee’s administrative staff serve as the task force’s
staff.
The task force must report its findings and recommendations to the
Insurance and Real Estate and Public Health committees by February 1,
2024. The task force terminates when it submits its report or on February
1, 2024, whichever is earlier.
§ 9 — MANAGED CARE O RGANIZATIONS REPORTS
Existing law requires managed care organizations (MCOs) to submit
an annual quality assurance plan to the insurance commissioner by May
1. The bill specifies that the statistical information included in the report
must be in a format the commissioner prescribes and include, in a
manner that allows the commissioner to compare plans (1) a list of
health care services that required prior authorization in the previous
calendar year and (2) the percent of services that required prior
authorization in the previous calendar year compared to the total
overall number of covered services. By law, the statistical information
must also include several other comparable criteria, such as the number
of utilization review determinations and the percent of employers that
renew their MCO contracts.
By law, the commissioner can accept these annual quality assurance
plans and other MCO reports electronically. The bill allows him to revise
the filing requirements to implement the statistical reporting provisions 2023SB-00006-R01-BA.DOCX
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described above.
Annually, also by May 1, the bill requires MCOs to submit to the
commissioner a report that summarizes (1) the actuarial analysis used
in setting standards for any procedures subject to prior authorization in
the previous calendar year and (2) any estimated premium savings
resulting from prior authorization and other utilization review
protocols. The commissioner must prescribe the report’s format.
§ 10 — CONSUMER REPO RT CARD
By law, the consumer report card is an annual report issued by the
insurance commissioner that contains certain comparative information
on health care centers (i.e., HMOs) and the 15 largest health insurers that
use provider networks in the state. The report card includes, for MCOs,
which include HMOs and insurers, a report on claims denials. Under
the bill, the report card must also include the actuarial analysis and
estimated premium savings information described above (see § 9).
§ 11 — ELECTRONIC UTILIZATION REVIEW PROCESSING
The bill requires participating providers (i.e., health care providers
who are contracted with a health carrier to provide services) to use a
carrier’s secure electronic program to process utilization review
requests. However, a participating provider’s failure to use the program
must not contribute to an adverse determination (e.g., a benefit denial).
COMMITTEE ACTION
Insurance and Real Estate Committee
Joint Favorable
Yea 7 Nay 5 (03/14/2023)
Appropriations Committee
Joint Favorable
Yea 37 Nay 16 (05/08/2023)