Connecticut 2023 Regular Session

Connecticut Senate Bill SB00006 Compare Versions

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Version 2 (New)

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7	7		General Assembly Committee Bill No. 6
8	8		January Session, 2023
9	9		LCO No. 4966
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12	12		Referred to Committee on INSURANCE AND REAL ESTATE
13	13
14	14
15	15		Introduced by:
16	16		(INS)
17	17
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19	19
20	20		AN ACT CONCERNING UTILIZATION REVIEW AND HEALTH CARE
21	21		CONTRACTS, HEALTH INSURANCE COVERAGE FOR NEWBORNS
22	22		AND STEP THERAPY.
23	23		Be it enacted by the Senate and House of Representatives in General
24	24		Assembly convened:
25	25
26	26		Section 1. (NEW) (Effective October 1, 2023) (a) As used in this section: 1
27	27		(1) "Evaluation" means: 2
28	28		(A) With respect to a health care service or course of treatment for 3
29	29		which a participating provider does not have a prospective or 4
30	30		concurrent review exemption, a review by a health carrier of 5
31	31		prospective or concurrent review exemption requests submitted by such 6
32	32		participating provider during the most recent evaluation period to 7
33	33		determine the percentage of such requests that were approved, for a 8
34	34		health carrier to evaluate whether to grant or deny a prospective or 9
35	35		concurrent review exemption; or 10
36	36		(B) With respect to a health care service or course of treatment for 11
37	37		which a participating provider has a prospective or concurrent review 12
38	38		exemption, a retrospective review by a health carrier of a random 13 Committee Bill No. 6
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40	40
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45	45		sample of payable claims submitted by such participating provider 14
46	46		during the most recent evaluation period to determine the percentage 15
47	47		of claims that would have been approved, based on meeting such health 16
48	48		carrier's applicable medical necessity criteria at the time the service was 17
49	49		provided, for such health carrier to evaluate whether to continue or 18
50	50		rescind a prospective or concurrent review exemption; and 19
51	51		(2) "Evaluation period" means the six-month period preceding an 20
52	52		evaluation. "Evaluation period" includes: 21
53	53		(A) For an initial determination of a prospective or concurrent review 22
54	54		exemption grant or denial for any health care service or course of 23
55	55		treatment, any six-month period that begins on January 1, 2024, July 1, 24
56	56		2024, or any subsequent six-month period that begins on any January 25
57	57		first or July first of any subsequent year; 26
58	58		(B) After a denial or rescission of a prospective or concurrent review 27
59	59		exemption for any health care service or course of treatment, the six-28
60	60		month period that commences on the first day following the end of the 29
61	61		evaluation period that formed the basis of such denial or rescission of a 30
62	62		prospective or concurrent review exemption; and 31
63	63		(C) For a notification of a prospective or concurrent review 32
64	64		exemption rescission, the six-month period after the health carrier 33
65	65		provided such notice of rescission to the participating provider or the 34
66	66		next six-month period, provided there shall not be more than two 35
67	67		months between the end of such evaluation period and the date such 36
68	68		notice is received by such participating provider. 37
69	69		(b) For any health care contract entered into, renewed or amended on 38
70	70		or after January 1, 2024, no health carrier that provides or performs 39
71	71		utilization review, including prospective and concurrent review, for any 40
72	72		health care service or course of treatment shall require that any 41
73	73		participating provider obtain prospective or concurrent review for any 42
74	74		health care service or course of treatment if, in the immediately 43
75	75		preceding six-month evaluation period, such health carrier approved 44 Committee Bill No. 6
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82	82		not less than ninety per cent of such prospective or concurrent review 45
83	83		requests submitted by such participating provider for such health care 46
84	84		service or course of treatment. 47
85	85		(c) Except for any exemption from the prospective or concurrent 48
86	86		review requirements that shall continue without evaluation pursuant to 49
87	87		subsection (f) of this section, each health carrier shall conduct an 50
88	88		evaluation once every six months to determine whether each 51
89	89		participating provider qualifies for an exemption from the prospective 52
90	90		or concurrent review requirements pursuant to subsection (b) of this 53
91	91		section. 54
92	92		(d) No participating provider shall be required to request an 55
93	93		exemption from such prospective or concurrent review requirements in 56
94	94		order to qualify for such exemption. 57
95	95		(e) Each participating provider's exemption from the prospective or 58
96	96		concurrent review requirements pursuant to subsection (b) of this 59
97	97		section, shall remain in effect until: 60
98	98		(1) The thirtieth day after the date on which the health carrier notifies 61
99	99		such participating provider of such health carrier's determination to 62
100	100		rescind such exemption pursuant to the provisions of subsection (g) of 63
101	101		this section, provided such participating provider does not appeal such 64
102	102		health carrier's determination in accordance with the provisions of 65
103	103		subsection (i) of this section; or 66
104	104		(2) If such participating provider appeals such health carrier's 67
105	105		determination in accordance with the provisions of subsection (i) of this 68
106	106		section and the independent review organization affirms such health 69
107	107		carrier's determination to rescind such exemption, the fifth day after the 70
108	108		date such independent review organization affirms such health carrier's 71
109	109		determination to rescind such exemption. 72
110	110		(f) If a health carrier does not finalize any determination to rescind 73
111	111		such exemption from the prospective or concurrent review 74
112	112		requirements in accordance with the provisions of subsection (e) of this 75 Committee Bill No. 6
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119	119		section, the participating provider shall automatically satisfy the 76
120	120		exemption from the prospective or concurrent review requirements 77
121	121		pursuant to subsection (b) of this section. 78
122	122		(g) Each health carrier may rescind any participating provider 79
123	123		exemption from the prospective or concurrent review requirements 80
124	124		under subsection (b) of this section only: 81
125	125		(1) During January or July of each year; 82
126	126		(2) If such health carrier makes a determination on the basis of a 83
127	127		retrospective review of a random sample of not less than five and not 84
128	128		more than twenty claims submitted by such participating provider 85
129	129		during the most recent evaluation period, as set forth in subsection (b) 86
130	130		of this section, that less than ninety per cent of such claims for the health 87
131	131		care service or course of treatment met the medical necessity criteria that 88
132	132		would have been used by such health carrier when conducting 89
133	133		prospective or concurrent review for the health care service or course of 90
134	134		treatment during the relevant evaluation period; and 91
135	135		(3) If such health carrier: 92
136	136		(A) Notifies such participating provider, in writing, not less than 93
137	137		thirty days before such rescission is to take effect; and 94
138	138		(B) Provides with such notice pursuant to subparagraph (A) of this 95
139	139		subdivision: 96
140	140		(i) The sample information used by such health carrier to make such 97
141	141		determination pursuant to subdivision (2) of this subsection; and 98
142	142		(ii) A plain language description identifying the process for such 99
143	143		participating provider to (I) submit an appeal of such rescission, and (II) 100
144	144		seek an independent review of such determination. 101
145	145		(h) No health carrier may deny an exemption from the prospective or 102
146	146		concurrent review requirements set forth in subsection (b) of this 103 Committee Bill No. 6
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153	153		section, unless such health carrier provides the participating provider 104
154	154		with statistics and data for the relevant prospective or concurrent 105
155	155		review evaluation period and information sufficient to demonstrate that 106
156	156		such participating provider fails to meet the criteria for an exemption 107
157	157		from the prospective or concurrent review requirements set forth in 108
158	158		subsection (b) of this section for each health care service or course of 109
159	159		treatment. 110
160	160		(i) (1) If a health carrier rescinds any participating provider's 111
161	161		exemption from the prospective or concurrent review requirements 112
162	162		pursuant to subsection (g) of this section, such participating provider 113
163	163		may request an independent review of such health carrier's 114
164	164		determination. Such independent review shall be conducted by an 115
165	165		independent review organization. No health carrier shall require a 116
166	166		participating provider to engage in an internal review process before 117
167	167		requesting an independent review of an adverse determination of an 118
168	168		exemption. 119
169	169		(2) Each health carrier that issues any adverse determination of a 120
170	170		participating provider's exemption pursuant to subsection (g) of this 121
171	171		section that is the subject of such independent review shall pay: 122
172	172		(A) The independent review organization for the cost of conducting 123
173	173		such independent review requested by such participating provider 124
174	174		pursuant to subdivision (1) of this subsection; and 125
175	175		(B) Reasonable fees for copies of all documents, communications, 126
176	176		information and evidence relating to the adverse determination of such 127
177	177		participating provider's exemption requested by such participating 128
178	178		provider for purposes of such independent review pursuant to this 129
179	179		subsection. The Insurance Commissioner shall adopt regulations, in 130
180	180		accordance with the provisions of chapter 54 of the general statutes, to 131
181	181		implement such fees that shall be paid by health carriers pursuant to 132
182	182		this subparagraph. 133
183	183		(3) Each independent review organization shall complete the review 134 Committee Bill No. 6
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190	190		of any adverse determination of the participating provider's exemption 135
191	191		not later than the thirtieth calendar day after the date that such 136
192	192		participating provider files such request for such independent review 137
193	193		under subdivision (1) of this subsection. 138
194	194		(4) The participating provider may request that the independent 139
195	195		review organization consider a random sample of not less than five and 140
196	196		not more than twenty claims submitted to the health carrier by such 141
197	197		participating provider during the relevant evaluation period for the 142
198	198		health care service or course of treatment that is subject to such 143
199	199		independent review as part of such independent review organization's 144
200	200		review. If such participating provider requests a review of such random 145
201	201		sample, such independent review organization shall base its 146
202	202		determination on the medical necessity of claims reviewed by such 147
203	203		health carrier under subdivision (2) of subsection (g) of this section and 148
204	204		by such independent review organization pursuant to this subdivision. 149
205	205		(j) (1) Each independent review determination shall be binding on the 150
206	206		health carrier and the participating provider, except to the extent such 151
207	207		health carrier or participating provider has other remedies available 152
208	208		under federal or state law. 153
209	209		(2) No health carrier shall retroactively deny any health care service 154
210	210		or course of treatment on the basis of a rescission of an exemption, even 155
211	211		if such health carrier's determination to rescind such prospective or 156
212	212		concurrent review exemption is affirmed by an independent review 157
213	213		organization. 158
214	214		(3) If any independent review organization overturns any health 159
215	215		carrier's determination of a prospective or concurrent review 160
216	216		exemption, such health carrier: 161
217	217		(A) Shall not attempt to rescind such exemption before the end of the 162
218	218		next evaluation period; and 163
219	219		(B) May only rescind such exemption after the end of the next 164
220	220		evaluation period, provided such health carrier complies with the 165 Committee Bill No. 6
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227	227		provisions of subsections (g) to (i), inclusive, of this section. 166
228	228		(k) After a final determination or review affirming a rescission or 167
229	229		denial of an exemption for a health care service or course of treatment, 168
230	230		any participating provider shall be eligible for reconsideration of such 169
231	231		exemption for the same health care service or course of treatment after 170
232	232		the end of the six-month evaluation period that follows such evaluation 171
233	233		period that formed the basis of the rescission or denial of such 172
234	234		exemption. 173
235	235		(l) (1) No health carrier shall deny or reduce payment to a 174
236	236		participating provider for any health care service or course of treatment 175
237	237		for which such participating provider has qualified for an exemption 176
238	238		from the prospective or concurrent review requirements pursuant to 177
239	239		subsection (b) of this section based on medical necessity or 178
240	240		appropriateness of care, unless such participating provider: 179
241	241		(A) Knowingly and materially misrepresented such health care 180
242	242		service or course of treatment in a request for payment submitted to 181
243	243		such health carrier; or 182
244	244		(B) Failed to substantially perform such health care service or course 183
245	245		of treatment. 184
246	246		(2) No health carrier shall conduct a retrospective review of any 185
247	247		health care service or course of treatment subject to an exemption 186
248	248		pursuant to subsection (b) of this section, except: 187
249	249		(A) To determine if a participating provider qualifies for such 188
250	250		exemption under subsection (b) of this section; or 189
251	251		(B) If such health carrier has reasonable cause to believe that a basis 190
252	252		for denial exists under subdivision (1) of this subsection. 191
253	253		(3) Not later than five business days after any participating provider 192
254	254		qualifies for an exemption from the prospective or concurrent review 193
255	255		requirements under subsection (b) of this section, the health carrier shall 194 Committee Bill No. 6
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262	262		provide to such participating provider a written notice that includes: 195
263	263		(A) A statement that such participating provider qualifies for an 196
264	264		exemption from the prospective or concurrent review requirements; 197
265	265		(B) A list of such participating provider's health care services or 198
266	266		course of treatments, and health benefit plans to which such exemption 199
267	267		applies; and 200
268	268		(C) A statement identifying the duration of such exemption. 201
269	269		(4) If a participating provider submits a prospective or concurrent 202
270	270		review request to a health carrier for any health care service or course of 203
271	271		treatment for which such participating provider qualifies for an 204
272	272		exemption from the prospective or concurrent review requirements 205
273	273		pursuant to subsection (b) of this section, such health carrier shall 206
274	274		promptly provide written notice to such participating provider that 207
275	275		includes: 208
276	276		(A) The information required under subparagraphs (A) to (C), 209
277	277		inclusive, of subdivision (3) of this subsection; and 210
278	278		(B) Notification of such health carrier's payment requirements. 211
279	279		(m) The commissioner shall adopt regulations, in accordance with the 212
280	280		provisions of chapter 54 of the general statutes, to carry out the 213
281	281		provisions of this section. 214
282	282		Sec. 2. Section 38a-591c of the general statutes is repealed and the 215
283	283		following is substituted in lieu thereof (Effective October 1, 2023): 216
284	284		(a) (1) Each health carrier shall contract with (A) health care 217
285	285		professionals to administer such health carrier's utilization review 218
286	286		program, and (B) clinical peers to evaluate the clinical appropriateness 219
287	287		of an adverse determination. 220
288	288		(2) (A) Each utilization review program shall use documented clinical 221
289	289		review criteria that are based on sound clinical evidence and are 222 Committee Bill No. 6
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296	296		evaluated periodically by the health carrier's organizational mechanism 223
297	297		specified in subparagraph (F) of subdivision (2) of subsection (c) of 224
298	298		section 38a-591b to assure such program's ongoing effectiveness. 225
299	299		(B) Except as provided in subdivisions (3), (4) and (5) of this 226
300	300		subsection, a health carrier may develop its own clinical review criteria 227
301	301		or it may purchase or license clinical review criteria from qualified 228
302	302		vendors approved by the commissioner, provided such clinical review 229
303	303		criteria conform to the requirements of subparagraph (A) of this 230
304	304		subdivision. 231
305	305		(C) Each health carrier shall (i) post on its Internet web site (I) any 232
306	306		clinical review criteria it uses, and (II) links to any rule, guideline, 233
307	307		protocol or other similar criterion a health carrier may rely upon to make 234
308	308		an adverse determination as described in subparagraph (F) of 235
309	309		subdivision (1) of subsection (e) of section 38a-591d, as amended by this 236
310	310		act, and (ii) make its clinical review criteria available upon request to 237
311	311		authorized government agencies. 238
312	312		(3) For any utilization review for the treatment of a substance use 239
313	313		disorder, as described in section 17a-458, the clinical review criteria used 240
314	314		shall be: (A) The most recent edition of the American Society of 241
315	315		Addiction Medicine Treatment Criteria for Addictive, Substance-242
316	316		Related, and Co-Occurring Conditions; or (B) clinical review criteria that 243
317	317		the health carrier demonstrates to the Insurance Department is 244
318	318		consistent with the most recent edition of the American Society of 245
319	319		Addiction Medicine Treatment Criteria for Addictive, Substance-246
320	320		Related, and Co-Occurring Conditions, except that nothing in this 247
321	321		subdivision shall prohibit a health carrier from developing its own 248
322	322		clinical review criteria or purchasing or licensing additional clinical 249
323	323		review criteria from qualified vendors approved by the commissioner, 250
324	324		to address advancements in technology or types of care for the 251
325	325		treatment of a substance use disorder, that are not covered in the most 252
326	326		recent edition of the American Society of Addiction Medicine Treatment 253
327	327		Criteria for Addictive, Substance-Related, and Co-Occurring 254
328	328		Conditions. Any such clinical review criteria developed by a health 255 Committee Bill No. 6
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335	335		carrier or purchased or licensed from a qualified vendor shall conform 256
336	336		to the requirements of subparagraph (A) of subdivision (2) of this 257
337	337		subsection. 258
338	338		(4) For any utilization review for the treatment of a child or 259
339	339		adolescent mental disorder, the clinical review criteria used shall be: (A) 260
340	340		The most recent guidelines of the American Academy of Child and 261
341	341		Adolescent Psychiatry's Child and Adolescent Service Intensity 262
342	342		Instrument; or (B) clinical review criteria that the health carrier 263
343	343		demonstrates to the Insurance Department is consistent with the most 264
344	344		recent guidelines of the American Academy of Child and Adolescent 265
345	345		Psychiatry's Child and Adolescent Service Intensity Instrument, except 266
346	346		that nothing in this subdivision shall prohibit a health carrier from 267
347	347		developing its own clinical review criteria or purchasing or licensing 268
348	348		additional clinical review criteria from qualified vendors approved by 269
349	349		the commissioner, to address advancements in technology or types of 270
350	350		care for the treatment of a child or adolescent mental disorder, that are 271
351	351		not covered in the most recent guidelines of the American Academy of 272
352	352		Child and Adolescent Psychiatry's Child and Adolescent Service 273
353	353		Intensity Instrument. Any such clinical review criteria developed by a 274
354	354		health carrier or purchased or licensed from a qualified vendor shall 275
355	355		conform to the requirements of subparagraph (A) of subdivision (2) of 276
356	356		this subsection. 277
357	357		(5) For any utilization review for the treatment of an adult mental 278
358	358		disorder, the clinical review criteria used shall be: (A) The most recent 279
359	359		guidelines of the American Psychiatric Association or the most recent 280
360	360		Standards and Guidelines of the Association for Ambulatory Behavioral 281
361	361		Healthcare; or (B) clinical review criteria that the health carrier 282
362	362		demonstrates to the Insurance Department is consistent with the most 283
363	363		recent guidelines of the American Psychiatric Association or the most 284
364	364		recent Standards and Guidelines of the Association for Ambulatory 285
365	365		Behavioral Healthcare, except that nothing in this subdivision shall 286
366	366		prohibit a health carrier from developing its own clinical review criteria 287
367	367		or purchasing or licensing additional clinical review criteria from 288 Committee Bill No. 6
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374	374		qualified vendors approved by the commissioner, to address 289
375	375		advancements in technology or types of care for the treatment of an 290
376	376		adult mental disorder, that are not covered in the most recent guidelines 291
377	377		of the American Psychiatric Association or the most recent Standards 292
378	378		and Guidelines of the Association for Ambulatory Behavioral 293
379	379		Healthcare. Any such clinical review criteria developed by a health 294
380	380		carrier or purchased or licensed from a qualified vendor shall conform 295
381	381		to the requirements of subparagraph (A) of subdivision (2) of this 296
382	382		subsection. 297
383	383		(b) Each health carrier shall: 298
384	384		(1) Have procedures in place to ensure that (A) the health care 299
385	385		professionals administering such health carrier's utilization review 300
386	386		program are applying the clinical review criteria consistently in 301
387	387		utilization review determinations, and (B) the appropriate or required 302
388	388		individual or individuals are being designated to conduct utilization 303
389	389		reviews; 304
390	390		(2) Have data systems sufficient to support utilization review 305
391	391		program activities and to generate management reports to enable the 306
392	392		health carrier to monitor and manage health care services effectively; 307
393	393		(3) Provide covered persons and participating providers with access 308
394	394		to its utilization review staff through a toll-free telephone number or 309
395	395		any other free calling option or by electronic means; 310
396	396		(4) Coordinate the utilization review program with other medical 311
397	397		management activity conducted by the health carrier, such as quality 312
398	398		assurance, credentialing, contracting with health care professionals, 313
399	399		data reporting, grievance procedures, processes for assessing member 314
400	400		satisfaction and risk management; and 315
401	401		(5) Routinely assess the effectiveness and efficiency of its utilization 316
402	402		review program. 317
403	403		(c) If a health carrier delegates any utilization review activities to a 318 Committee Bill No. 6
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410	410		utilization review company, the health carrier shall maintain adequate 319
411	411		oversight, which shall include (1) a written description of the utilization 320
412	412		review company's activities and responsibilities, including such 321
413	413		company's reporting requirements, (2) evidence of the health carrier's 322
414	414		formal approval of the utilization review company program, and (3) a 323
415	415		process by which the health carrier shall evaluate the utilization review 324
416	416		company's performance. 325
417	417		(d) When conducting utilization review, the health carrier shall (1) 326
418	418		collect only the information necessary, including pertinent clinical 327
419	419		information, to make the utilization review or benefit determination, 328
420	420		and (2) ensure that such review is conducted in a manner to ensure the 329
421	421		independence and impartiality of the individual or individuals involved 330
422	422		in making the utilization review or benefit determination. No health 331
423	423		carrier shall make decisions regarding the hiring, compensation, 332
424	424		termination, promotion or other similar matters of such individual or 333
425	425		individuals based on the likelihood that the individual or individuals 334
426	426		will support the denial of benefits. 335
427	427		(e) Not later than January 1, 2024, each health carrier shall establish 336
428	428		an electronic program to provide for the secure electronic: 337
429	429		(1) Filing of prospective and concurrent review requests, and other 338
430	430		requests for prospective or concurrent utilization reviews, by hospital 339
431	431		and health care professionals with such health carrier, and submission 340
432	432		of available clinical information in support of such requests; and 341
433	433		(2) Transmission of such health carrier's responses to such requests 342
434	434		described in subdivision (1) of this subsection. 343
435	435		Sec. 3. Section 38a-591d of the general statutes is repealed and the 344
436	436		following is substituted in lieu thereof (Effective October 1, 2023): 345
437	437		(a) (1) Each health carrier shall maintain written procedures for (A) 346
438	438		utilization review and benefit determinations, (B) expedited utilization 347
439	439		review and benefit determinations with respect to prospective urgent 348
440	440		care requests and concurrent review urgent care requests, and (C) 349 Committee Bill No. 6
441	441
442	442
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446	446
447	447		notifying covered persons or covered persons' authorized 350
448	448		representatives of such review and benefit determinations. Each health 351
449	449		carrier shall make such review and benefit determinations within the 352
450	450		specified time periods under this section. 353
451	451		(2) In determining whether a benefit request shall be considered an 354
452	452		urgent care request, an individual acting on behalf of a health carrier 355
453	453		shall apply the judgment of a prudent layperson who possesses an 356
454	454		average knowledge of health and medicine, except that any benefit 357
455	455		request (A) determined to be an urgent care request by a health care 358
456	456		professional with knowledge of the covered person's medical condition, 359
457	457		or (B) specified under subparagraph (B) or (C) of subdivision (38) of 360
458	458		section 38a-591a shall be deemed an urgent care request. 361
459	459		(3) (A) At the time a health carrier notifies a covered person, a covered 362
460	460		person's authorized representative or a covered person's health care 363
461	461		professional of an initial adverse determination that was based, in whole 364
462	462		or in part, on medical necessity, of a concurrent or prospective 365
463	463		utilization review or of a benefit request, the health carrier shall notify 366
464	464		the covered person's health care professional (i) of the opportunity for a 367
465	465		conference as provided in subparagraph (B) of this subdivision, and (ii) 368
466	466		that such conference shall not be considered a grievance of such initial 369
467	467		adverse determination as long as a grievance has not been filed as set 370
468	468		forth in subparagraph (B) of this subdivision. 371
469	469		(B) After a health carrier notifies a covered person, a covered person's 372
470	470		authorized representative or a covered person's health care professional 373
471	471		of an initial adverse determination that was based, in whole or in part, 374
472	472		on medical necessity, of a concurrent or prospective utilization review 375
473	473		or of a benefit request, the health carrier shall offer a covered person's 376
474	474		health care professional the opportunity to confer, at the request of the 377
475	475		covered person's health care professional, with a clinical peer of such 378
476	476		health carrier, provided such covered person, covered person's 379
477	477		authorized representative or covered person's health care professional 380
478	478		has not filed a grievance of such initial adverse determination prior to 381
479	479		such conference. Such conference shall not be considered a grievance of 382 Committee Bill No. 6
480	480
481	481
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485	485
486	486		such initial adverse determination. 383
487	487		(b) With respect to a nonurgent care request: 384
488	488		(1) (A) For a prospective or concurrent review request, a health carrier 385
489	489		shall make a determination within a reasonable period of time 386
490	490		appropriate to the covered person's medical condition, but not later than 387
491	491		[fifteen calendar days] seventy-two hours after the date the health 388
492	492		carrier receives such request, and shall notify the covered person and, if 389
493	493		applicable, the covered person's authorized representative of such 390
494	494		determination, whether or not the carrier certifies the provision of the 391
495	495		benefit. 392
496	496		(B) If the review under subparagraph (A) of this subdivision is a 393
497	497		review of a grievance involving a concurrent review request, pursuant 394
498	498		to 45 CFR 147.136, as amended from time to time, the treatment shall be 395
499	499		continued without liability to the covered person until the covered 396
500	500		person has been notified of the review decision. 397
501	501		(2) For a retrospective review request, a health carrier shall make a 398
502	502		determination within a reasonable period of time, but not later than 399
503	503		thirty calendar days after the date the health carrier receives such 400
504	504		request. 401
505	505		(3) The time periods specified in subdivisions (1) and (2) of this 402
506	506		subsection may be extended once by the health carrier for up to [fifteen 403
507	507		calendar days] seventy-two hours, provided the health carrier: 404
508	508		(A) Determines that an extension is necessary due to circumstances 405
509	509		beyond the health carrier's control; and 406
510	510		(B) Notifies the covered person and, if applicable, the covered 407
511	511		person's authorized representative prior to the expiration of the initial 408
512	512		time period, of the circumstances requiring the extension of time and 409
513	513		the date by which the health carrier expects to make a determination. 410
514	514		(4) (A) If the extension pursuant to subdivision (3) of this subsection 411 Committee Bill No. 6
515	515
516	516
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520	520
521	521		is necessary due to the failure of the covered person or the covered 412
522	522		person's authorized representative to provide information necessary to 413
523	523		make a determination on the request, the health carrier shall: 414
524	524		(i) Specifically describe in the notice of extension the required 415
525	525		information necessary to complete the request; and 416
526	526		(ii) Provide the covered person and, if applicable, the covered 417
527	527		person's authorized representative with not less than forty-five calendar 418
528	528		days after the date of receipt of the notice to provide the specified 419
529	529		information. 420
530	530		(B) If the covered person or the covered person's authorized 421
531	531		representative fails to submit the specified information before the end 422
532	532		of the period of the extension, the health carrier may deny certification 423
533	533		of the benefit requested. 424
534	534		(c) With respect to an urgent care request: 425
535	535		(1) (A) Unless the covered person or the covered person's authorized 426
536	536		representative has failed to provide information necessary for the health 427
537	537		carrier to make a determination and except as specified under 428
538	538		subparagraph (B) of this subdivision, the health carrier shall make a 429
539	539		determination as soon as possible, taking into account the covered 430
540	540		person's medical condition, but not later than [forty-eight] twenty-four 431
541	541		hours after the health carrier receives such request, [or seventy-two 432
542	542		hours after such health carrier receives such request if any portion of 433
543	543		such forty-eight-hour period falls on a weekend,] provided, if the urgent 434
544	544		care request is a concurrent review request to extend a course of 435
545	545		treatment beyond the initial period of time or the number of treatments, 436
546	546		such request is made [at least] not less than twenty-four hours prior to 437
547	547		the expiration of the prescribed period of time or number of treatments. 438
548	548		(B) Unless the covered person or the covered person's authorized 439
549	549		representative has failed to provide information necessary for the health 440
550	550		carrier to make a determination, for an urgent care request specified 441
551	551		under subparagraph (B) or (C) of subdivision (38) of section 38a-591a, 442 Committee Bill No. 6
552	552
553	553
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557	557
558	558		the health carrier shall make a determination as soon as possible, taking 443
559	559		into account the covered person's medical condition, but not later than 444
560	560		twenty-four hours after the health carrier receives such request, 445
561	561		provided, if the urgent care request is a concurrent review request to 446
562	562		extend a course of treatment beyond the initial period of time or the 447
563	563		number of treatments, such request is made [at least] not less than 448
564	564		twenty-four hours prior to the expiration of the prescribed period of 449
565	565		time or number of treatments. 450
566	566		(2) (A) If the covered person or the covered person's authorized 451
567	567		representative has failed to provide information necessary for the health 452
568	568		carrier to make a determination, the health carrier shall notify the 453
569	569		covered person or the covered person's representative, as applicable, as 454
570	570		soon as possible, but not later than twenty-four hours after the health 455
571	571		carrier receives such request. 456
572	572		(B) The health carrier shall provide the covered person or the covered 457
573	573		person's authorized representative, as applicable, a reasonable period of 458
574	574		time to submit the specified information, taking into account the 459
575	575		covered person's medical condition, but not less than forty-eight hours 460
576	576		after notifying the covered person or the covered person's authorized 461
577	577		representative, as applicable. 462
578	578		(3) The health carrier shall notify the covered person and, if 463
579	579		applicable, the covered person's authorized representative of its 464
580	580		determination as soon as possible, but not later than forty-eight hours 465
581	581		after the earlier of (A) the date on which the covered person and the 466
582	582		covered person's authorized representative, as applicable, provides the 467
583	583		specified information to the health carrier, or (B) the date on which the 468
584	584		specified information was to have been submitted. 469
585	585		(d) (1) [Whenever a health carrier receives a review request from a 470
586	586		covered person or a covered person's authorized representative that 471
587	587		fails to meet the health carrier's filing procedures, the health carrier shall 472
588	588		notify the covered person and, if applicable, the covered person's 473
589	589		authorized representative of such failure not later than five calendar 474 Committee Bill No. 6
590	590
591	591
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595	595
596	596		days after the health carrier receives such request, except that for an 475
597	597		urgent care request, the health carrier shall notify the covered person 476
598	598		and, if applicable, the covered person's authorized representative of 477
599	599		such failure not later than twenty-four hours after the health carrier 478
600	600		receives such request.] With respect to prospective and concurrent 479
601	601		review requests, each health carrier shall: 480
602	602		(A) Process prospective and concurrent review requests twenty-four 481
603	603		hours a day, seven days a week, including holidays; and 482
604	604		(B) Acknowledge receipt of each nonurgent prospective and 483
605	605		concurrent review request as soon as practicable, but not later than 484
606	606		twenty-four hours following such health carrier's receipt of such 485
607	607		prospective and concurrent review request, except that such health 486
608	608		carrier shall respond in less time if such a response is required by 487
609	609		applicable federal law. 488
610	610		(2) [If the health carrier provides such notice orally, the health carrier 489
611	611		shall provide confirmation in writing to the covered person and the 490
612	612		covered person's health care professional of record not later than five 491
613	613		calendar days after providing the oral notice] No health carrier shall 492
614	614		require a health care professional or hospital to submit additional 493
615	615		information that was not reasonably available to such health care 494
616	616		professional or hospital at the time that such health care professional or 495
617	617		hospital filed the prospective or concurrent review request with such 496
618	618		health carrier. 497
619	619		(e) Each health carrier shall provide promptly to a covered person 498
620	620		and, if applicable, the covered person's authorized representative a 499
621	621		notice of an adverse determination. 500
622	622		(1) Such notice may be provided in writing or by electronic means 501
623	623		and shall set forth, in a manner calculated to be understood by the 502
624	624		covered person or the covered person's authorized representative: 503
625	625		(A) Information sufficient to identify the benefit request or claim 504
626	626		involved, including the date of service, if applicable, the health care 505 Committee Bill No. 6
627	627
628	628
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632	632
633	633		professional and the claim amount; 506
634	634		(B) The specific reason or reasons for the adverse determination, 507
635	635		including, upon request, a listing of the relevant clinical review criteria, 508
636	636		including professional criteria and medical or scientific evidence and a 509
637	637		description of the health carrier's standard, if any, that were used in 510
638	638		reaching the denial; 511
639	639		(C) Reference to the specific health benefit plan provisions on which 512
640	640		the determination is based; 513
641	641		(D) A description of any additional material or information necessary 514
642	642		for the covered person to perfect the benefit request or claim, including 515
643	643		an explanation of why the material or information is necessary to perfect 516
644	644		the request or claim; 517
645	645		(E) A description of the health carrier's internal grievance process that 518
646	646		includes (i) the health carrier's expedited review procedures, (ii) any 519
647	647		time limits applicable to such process or procedures, (iii) the contact 520
648	648		information for the organizational unit designated to coordinate the 521
649	649		review on behalf of the health carrier, and (iv) a statement that the 522
650	650		covered person or, if applicable, the covered person's authorized 523
651	651		representative is entitled, pursuant to the requirements of the health 524
652	652		carrier's internal grievance process, to receive from the health carrier, 525
653	653		free of charge upon request, reasonable access to and copies of all 526
654	654		documents, records, communications and other information and 527
655	655		evidence regarding the covered person's benefit request; 528
656	656		(F) (i) (I) A copy of the specific rule, guideline, protocol or other 529
657	657		similar criterion the health carrier relied upon to make the adverse 530
658	658		determination, or (II) a statement that a specific rule, guideline, protocol 531
659	659		or other similar criterion of the health carrier was relied upon to make 532
660	660		the adverse determination and that a copy of such rule, guideline, 533
661	661		protocol or other similar criterion will be provided to the covered person 534
662	662		free of charge upon request, with instructions for requesting such copy, 535
663	663		and (ii) the links to such rule, guideline, protocol or other similar 536 Committee Bill No. 6
664	664
665	665
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669	669
670	670		criterion on such health carrier's Internet web site; 537
671	671		(G) If the adverse determination is based on medical necessity or an 538
672	672		experimental or investigational treatment or similar exclusion or limit, 539
673	673		the written statement of the scientific or clinical rationale for the adverse 540
674	674		determination and (i) an explanation of the scientific or clinical rationale 541
675	675		used to make the determination that applies the terms of the health 542
676	676		benefit plan to the covered person's medical circumstances or (ii) a 543
677	677		statement that an explanation will be provided to the covered person 544
678	678		free of charge upon request, and instructions for requesting a copy of 545
679	679		such explanation; 546
680	680		(H) A statement explaining the right of the covered person to contact 547
681	681		the commissioner's office or the Office of the Healthcare Advocate at 548
682	682		any time for assistance or, upon completion of the health carrier's 549
683	683		internal grievance process, to file a civil action in a court of competent 550
684	684		jurisdiction. Such statement shall include the contact information for 551
685	685		said offices; and 552
686	686		(I) A statement, expressed in language approved by the Healthcare 553
687	687		Advocate and prominently displayed on the first page or cover sheet of 554
688	688		the notice using a call-out box and large or bold text, that if the covered 555
689	689		person or the covered person's authorized representative chooses to file 556
690	690		a grievance of an adverse determination, (i) such appeals are sometimes 557
691	691		successful, (ii) such covered person or covered person's authorized 558
692	692		representative may benefit from free assistance from the Office of the 559
693	693		Healthcare Advocate, which can assist such covered person or covered 560
694	694		person's authorized representative with the filing of a grievance 561
695	695		pursuant to 42 USC 300gg-93, as amended from time to time, (iii) such 562
696	696		covered person or covered person's authorized representative is entitled 563
697	697		and encouraged to submit supporting documentation for the health 564
698	698		carrier's consideration during the review of an adverse determination, 565
699	699		including narratives from such covered person or covered person's 566
700	700		authorized representative and letters and treatment notes from such 567
701	701		covered person's health care professional, and (iv) such covered person 568
702	702		or covered person's authorized representative has the right to ask such 569 Committee Bill No. 6
703	703
704	704
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708	708
709	709		covered person's health care professional for such letters or treatment 570
710	710		notes. 571
711	711		(2) Upon request pursuant to subparagraph (E) of subdivision (1) of 572
712	712		this subsection, the health carrier shall provide such copies in 573
713	713		accordance with subsection (a) of section 38a-591n. 574
714	714		(f) If the adverse determination is a rescission, the health carrier shall 575
715	715		include with the advance notice of the application for rescission 576
716	716		required to be sent to the covered person, a written statement that 577
717	717		includes: 578
718	718		(1) Clear identification of the alleged fraudulent act, practice or 579
719	719		omission or the intentional misrepresentation of material fact; 580
720	720		(2) An explanation as to why the act, practice or omission was 581
721	721		fraudulent or was an intentional misrepresentation of a material fact; 582
722	722		(3) A disclosure that the covered person or the covered person's 583
723	723		authorized representative may file immediately, without waiting for the 584
724	724		date such advance notice of the proposed rescission ends, a grievance 585
725	725		with the health carrier to request a review of the adverse determination 586
726	726		to rescind coverage, pursuant to sections 38a-591e and 38a-591f; 587
727	727		(4) A description of the health carrier's grievance procedures 588
728	728		established under sections 38a-591e and 38a-591f, including any time 589
729	729		limits applicable to those procedures; and 590
730	730		(5) The date such advance notice of the proposed rescission ends and 591
731	731		the date back to which the coverage will be retroactively rescinded. 592
732	732		(g) (1) Whenever a health carrier fails to strictly adhere to the 593
733	733		requirements of this section with respect to making utilization review 594
734	734		and benefit determinations of a benefit request or claim, the covered 595
735	735		person shall be deemed to have exhausted the internal grievance 596
736	736		process of such health carrier and may file a request for an external 597
737	737		review in accordance with the provisions of section 38a-591g, regardless 598 Committee Bill No. 6
738	738
739	739
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743	743
744	744		of whether the health carrier asserts it substantially complied with the 599
745	745		requirements of this section or that any error it committed was de 600
746	746		minimis. 601
747	747		(2) A covered person who has exhausted the internal grievance 602
748	748		process of a health carrier may, in addition to filing a request for an 603
749	749		external review, pursue any available remedies under state or federal 604
750	750		law on the basis that the health carrier failed to provide a reasonable 605
751	751		internal grievance process that would yield a decision on the merits of 606
752	752		the claim. 607
753	753		Sec. 4. Section 38a-490 of the general statutes is repealed and the 608
754	754		following is substituted in lieu thereof (Effective October 1, 2023): 609
755	755		(a) Each individual health insurance policy delivered, issued for 610
756	756		delivery, renewed, amended or continued in this state providing 611
757	757		coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) 612
758	758		and (12) of section 38a-469 for a family member of the insured or 613
759	759		subscriber shall, as to such family member's coverage, also provide that 614
760	760		the health insurance benefits applicable for children shall be payable 615
761	761		with respect to a newly born child of the insured or subscriber from the 616
762	762		moment of birth. 617
763	763		(b) Coverage for such newly born child shall consist of coverage for 618
764	764		injury and sickness including necessary care and treatment of medically 619
765	765		diagnosed congenital defects and birth abnormalities within the limits 620
766	766		of the policy. 621
767	767		(c) If payment of a specific premium or subscription fee is required to 622
768	768		provide coverage for a child, the policy or contract may require that 623
769	769		notification of birth of such newly born child and payment of the 624
770	770		required premium or fees shall be furnished to the insurer, hospital 625
771	771		service corporation, medical service corporation or health care center 626
772	772		not later than [sixty-one] one hundred twenty-one days after the date of 627
773	773		birth or the date of discharge from the hospital, whichever is later, in 628
774	774		order to continue coverage beyond such [sixty-one-day] period, 629 Committee Bill No. 6
775	775
776	776
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780	780
781	781		provided failure to furnish such notice or pay such premium or fees 630
782	782		shall not prejudice any claim originating within such [sixty-one-day] 631
783	783		period. 632
784	784		Sec. 5. Section 38a-516 of the general statutes is repealed and the 633
785	785		following is substituted in lieu thereof (Effective October 1, 2023): 634
786	786		(a) Each group health insurance policy delivered, issued for delivery, 635
787	787		renewed, amended or continued in this state providing coverage of the 636
788	788		type specified in subdivisions (1), (2), (4), (6), (11) and (12) of section 38a-637
789	789		469 for a family member of the insured or subscriber shall, as to such 638
790	790		family member's coverage, also provide that the health insurance 639
791	791		benefits applicable for children shall be payable with respect to a newly 640
792	792		born child of the insured or subscriber from the moment of birth. 641
793	793		(b) Coverage for such newly born child shall consist of coverage for 642
794	794		injury and sickness including necessary care and treatment of medically 643
795	795		diagnosed congenital defects and birth abnormalities within the limits 644
796	796		of the policy. 645
797	797		(c) If payment of a specific premium fee is required to provide 646
798	798		coverage for a child, the policy may require that notification of birth of 647
799	799		such newly born child and payment of the required premium or fees 648
800	800		shall be furnished to the insurer, hospital service corporation, medical 649
801	801		service corporation or health care center not later than [sixty-one] one 650
802	802		hundred twenty-one days after the date of birth or the date of discharge 651
803	803		from the hospital, whichever is later, in order to continue coverage 652
804	804		beyond such [sixty-one-day] period, provided failure to furnish such 653
805	805		notice or pay such premium shall not prejudice any claim originating 654
806	806		within such [sixty-one-day] period. 655
807	807		Sec. 6. Subsection (a) of section 38a-510 of the general statutes is 656
808	808		repealed and the following is substituted in lieu thereof (Effective October 657
809	809		1, 2023): 658
810	810		(a) No insurance company, hospital service corporation, medical 659
811	811		service corporation, health care center or other entity delivering, issuing 660 Committee Bill No. 6
812	812
813	813
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817	817
818	818		for delivery, renewing, amending or continuing an individual health 661
819	819		insurance policy or contract that provides coverage for prescription 662
820	820		drugs may: 663
821	821		(1) Require any person covered under such policy or contract to 664
822	822		obtain prescription drugs from a mail order pharmacy as a condition of 665
823	823		obtaining benefits for such drugs; or 666
824	824		(2) Require, if such insurance company, hospital service corporation, 667
825	825		medical service corporation, health care center or other entity uses step 668
826	826		therapy for such drugs, the use of step therapy for: 669
827	827		(A) [any] Any prescribed drug for longer than sixty days; [,] or 670
828	828		(B) [a] A prescribed drug for [cancer] treatment of a behavioral health 671
829	829		condition or a chronic, disabling or life-threatening condition or disease 672
830	830		for an insured who has been diagnosed with [stage IV metastatic cancer] 673
831	831		such a condition or disease, provided such prescribed drug is in 674
832	832		compliance with approved federal Food and Drug Administration 675
833	833		indications. 676
834	834		(3) At the expiration of the time period specified in subparagraph (A) 677
835	835		of subdivision (2) of this subsection, [or for a prescribed drug described 678
836	836		in subparagraph (B) of subdivision (2) of this subsection,] an insured's 679
837	837		treating health care provider may deem such step therapy drug regimen 680
838	838		clinically ineffective for the insured, at which time the insurance 681
839	839		company, hospital service corporation, medical service corporation, 682
840	840		health care center or other entity shall authorize dispensation of and 683
841	841		coverage for the drug prescribed by the insured's treating health care 684
842	842		provider, provided such drug is a covered drug under such policy or 685
843	843		contract. If such provider does not deem such step therapy drug 686
844	844		regimen clinically ineffective or has not requested an override pursuant 687
845	845		to subdivision (1) of subsection (b) of this section, such drug regimen 688
846	846		may be continued. For purposes of this section, "step therapy" means a 689
847	847		protocol or program that establishes the specific sequence in which 690
848	848		prescription drugs for a specified medical condition are to be prescribed. 691 Committee Bill No. 6
849	849
850	850
851	851		LCO 4966 {\\PRDFS1\SCOUSERS\FORZANOF\WS\2023SB-00006-
852		-	~~R03~~-SB.docx }
	852	+	R02-SB.docx }
853	853		24 of 25
854	854
855	855		Sec. 7. Subsection (a) of section 38a-544 of the general statutes is 692
856	856		repealed and the following is substituted in lieu thereof (Effective October 693
857	857		1, 2023): 694
858	858		(a) No insurance company, hospital service corporation, medical 695
859	859		service corporation, health care center or other entity delivering, issuing 696
860	860		for delivery, renewing, amending or continuing a group health 697
861	861		insurance policy or contract that provides coverage for prescription 698
862	862		drugs may: 699
863	863		(1) Require any person covered under such policy or contract to 700
864	864		obtain prescription drugs from a mail order pharmacy as a condition of 701
865	865		obtaining benefits for such drugs; or 702
866	866		(2) Require, if such insurance company, hospital service corporation, 703
867	867		medical service corporation, health care center or other entity uses step 704
868	868		therapy for such drugs, the use of step therapy for: 705
869	869		(A) [any] Any prescribed drug for longer than sixty days; [,] or 706
870	870		(B) [a] A prescribed drug for [cancer] treatment of a behavioral health 707
871	871		condition or a chronic, disabling or life-threatening condition or disease 708
872	872		for an insured who has been diagnosed with [stage IV metastatic cancer] 709
873	873		such a condition or disease, provided such prescribed drug is in 710
874	874		compliance with approved federal Food and Drug Administration 711
875	875		indications. 712
876	876		(3) At the expiration of the time period specified in subparagraph (A) 713
877	877		of subdivision (2) of this subsection, [or for a prescribed drug described 714
878	878		in subparagraph (B) of subdivision (2) of this subsection,] an insured's 715
879	879		treating health care provider may deem such step therapy drug regimen 716
880	880		clinically ineffective for the insured, at which time the insurance 717
881	881		company, hospital service corporation, medical service corporation, 718
882	882		health care center or other entity shall authorize dispensation of and 719
883	883		coverage for the drug prescribed by the insured's treating health care 720
884	884		provider, provided such drug is a covered drug under such policy or 721
885	885		contract. If such provider does not deem such step therapy drug 722 Committee Bill No. 6
886	886
887	887
888	888		LCO 4966 {\\PRDFS1\SCOUSERS\FORZANOF\WS\2023SB-00006-
889		-	~~R03~~-SB.docx }
	889	+	R02-SB.docx }
890	890		25 of 25
891	891
892	892		regimen clinically ineffective or has not requested an override pursuant 723
893	893		to subdivision (1) of subsection (b) of this section, such drug regimen 724
894	894		may be continued. For purposes of this section, "step therapy" means a 725
895	895		protocol or program that establishes the specific sequence in which 726
896	896		prescription drugs for a specified medical condition are to be prescribed. 727
897	897		Sec. 8. (NEW) (Effective October 1, 2023) No health carrier shall require 728
898	898		a prospective or concurrent review of a recurring health care service or 729
899	899		prescription drug after such health carrier has certified such health care 730
900	900		service or prescription drug through utilization review. Nothing in this 731
901	901		section shall require a health carrier to cover any health care service or 732
902	902		prescription drug for a health condition of which the terms of coverage 733
903	903		completely exclude such health care service or prescription drug from 734
904	904		the policy's covered benefits. 735
905	905		This act shall take effect as follows and shall amend the following
906	906		sections:
907	907
908	908		Section 1 October 1, 2023 New section
909	909		Sec. 2 October 1, 2023 38a-591c
910	910		Sec. 3 October 1, 2023 38a-591d
911	911		Sec. 4 October 1, 2023 38a-490
912	912		Sec. 5 October 1, 2023 38a-516
913	913		Sec. 6 October 1, 2023 38a-510(a)
914	914		Sec. 7 October 1, 2023 38a-544(a)
915	915		Sec. 8 October 1, 2023 New section
916	916
917	917		INS Joint Favorable
918		-	APP Joint Favorable
919	918