Connecticut 2024 Regular Session

Connecticut Senate Bill SB00180 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
1	1
2	2
3		-	LCO 1486 \\PRDFS1\SCOUSERS\FORZANOF\WS\2024SB-00180-R01-
4		-	SB.docx
5		-	1 of 8
	3	+	LCO No. 1486 1 of 8
6	4
7	5		General Assembly Raised Bill No. 180
8	6		February Session, 2024
9	7		LCO No. 1486
10	8
11	9
12	10		Referred to Committee on PUBLIC HEALTH
13	11
14	12
15	13		Introduced by:
16	14		(PH)
	15	+
17	16
18	17
19	18
20	19		AN ACT CONCERNING ADVERSE DETERMINATION AND
21	20		UTILIZATION REVIEWS.
22	21		Be it enacted by the Senate and House of Representatives in General
23	22		Assembly convened:
24	23
25	24		Section 1. Subdivision (7) of section 38a-591a of the 2024 supplement 1
26	25		to the general statutes is repealed and the following is substituted in lieu 2
27	26		thereof (Effective January 1, 2025): 3
28	27		(7) "Clinical peer" means a physician or other health care professional 4
29	28		who: 5
30	29		(A) [holds] For a review other than one specified under subparagraph 6
31	30		(B) or (C) of subdivision (38) of this section, holds a nonrestricted license 7
32	31		in a state of the United States [and] in the same [or similar] specialty as 8
33	32		[typically manages the medical condition, procedure or treatment] the 9
34	33		treating physician or other health care professional under review; [, and] 10
35	34		or 11
36	35		(B) [for] For a review specified under subparagraph (B) or (C) of 12
37		-	subdivision (38) of this section concerning: 13 Bill No. 180
	36	+	subdivision (38) of this section concerning: 13 Raised Bill No. 180
38	37
39	38
40		-	LCO 1486 {\\PRDFS1\SCOUSERS\FORZANOF\WS\2024SB-00180-
41		-	R01-SB.docx }
42		-	2 of 8
	39	+
	40	+	LCO No. 1486 2 of 8
43	41
44	42		(i) [a] A child or adolescent substance use disorder or a child or 14
45	43		adolescent mental disorder, holds (I) a national board certification in 15
46	44		child and adolescent psychiatry, or (II) a doctoral level psychology 16
47	45		degree with training and clinical experience in the treatment of child 17
48	46		and adolescent substance use disorder or child and adolescent mental 18
49	47		disorder, as applicable; [,] or 19
50	48		(ii) [an] An adult substance use disorder or an adult mental disorder, 20
51	49		holds (I) a national board certification in psychiatry, or (II) a doctoral 21
52	50		level psychology degree with training and clinical experience in the 22
53	51		treatment of adult substance use disorders or adult mental disorders, as 23
54	52		applicable. 24
55	53		Sec. 2. Subsection (a) of section 38a-591c of the 2024 supplement to 25
56	54		the general statutes is repealed and the following is substituted in lieu 26
57	55		thereof (Effective January 1, 2025): 27
58	56		(a) (1) Each health carrier shall contract with (A) health care 28
59	57		professionals to administer such health carrier's utilization review 29
60	58		program, and (B) clinical peers to evaluate the clinical appropriateness 30
61	59		of an adverse determination. 31
62	60		(2) (A) Each utilization review program shall use documented clinical 32
63	61		review criteria that are based on sound clinical evidence and are 33
64	62		evaluated periodically by the health carrier's organizational mechanism 34
65	63		specified in subparagraph (F) of subdivision (2) of subsection (c) of 35
66	64		section 38a-591b to [assure] ensure such program's ongoing 36
67	65		effectiveness. 37
68	66		(B) Except as provided in subdivisions (3), (4) and (5) of this 38
69	67		subsection, a health carrier may develop its own clinical review criteria 39
70	68		or it may purchase or license clinical review criteria from qualified 40
71	69		vendors approved by the commissioner, provided such clinical review 41
72	70		criteria conform to the requirements of subparagraph (A) of this 42
73	71		subdivision. 43
74		-	(C) Each health carrier shall (i) post on its Internet web site (I) any 44 Bill No. 180
	72	+	(C) Each health carrier shall (i) post on its Internet web site (I) any 44 Raised Bill No. 180
75	73
76	74
77		-	LCO 1486 {\\PRDFS1\SCOUSERS\FORZANOF\WS\2024SB-00180-
78		-	R01-SB.docx }
79		-	3 of 8
	75	+
	76	+	LCO No. 1486 3 of 8
80	77
81	78		clinical review criteria it uses, and (II) links to any rule, guideline, 45
82	79		protocol or other similar criterion a health carrier may rely upon to make 46
83	80		an adverse determination as described in subparagraph (F) of 47
84	81		subdivision (1) of subsection (e) of section 38a-591d, and (ii) make its 48
85	82		clinical review criteria available upon request to authorized government 49
86	83		agencies. 50
87	84		(D) For each utilization review, there shall be a rebuttable 51
88	85		presumption that each health care service under review is medically 52
89	86		necessary if such health care service was ordered by a health care 53
90	87		professional acting within the health care professional's scope of 54
91	88		practice. A health carrier, or any utilization review company or designee 55
92	89		of a health carrier that performs utilization review on behalf of the 56
93	90		health carrier, shall have the burden of proving that a health care service 57
94	91		is not medically necessary. 58
95	92		(3) For any utilization review for the treatment of a substance use 59
96	93		disorder, as described in section 17a-458, the clinical review criteria used 60
97	94		shall be: (A) The most recent edition of the American Society of 61
98	95		Addiction Medicine Treatment Criteria for Addictive, Substance-62
99	96		Related, and Co-Occurring Conditions; or (B) clinical review criteria that 63
100	97		the health carrier demonstrates to the Insurance Department is 64
101	98		consistent with the most recent edition of the American Society of 65
102	99		Addiction Medicine Treatment Criteria for Addictive, Substance-66
103	100		Related, and Co-Occurring Conditions, except that nothing in this 67
104	101		subdivision shall prohibit a health carrier from developing its own 68
105	102		clinical review criteria or purchasing or licensing additional clinical 69
106	103		review criteria from qualified vendors approved by the commissioner, 70
107	104		to address advancements in technology or types of care for the 71
108	105		treatment of a substance use disorder, that are not covered in the most 72
109	106		recent edition of the American Society of Addiction Medicine Treatment 73
110	107		Criteria for Addictive, Substance-Related, and Co-Occurring 74
111	108		Conditions. Any such clinical review criteria developed by a health 75
112	109		carrier or purchased or licensed from a qualified vendor shall conform 76
113		-	to the requirements of subparagraph (A) of subdivision (2) of this 77 Bill No. 180
	110	+	to the requirements of subparagraph (A) of subdivision (2) of this 77
	111	+	subsection. 78 Raised Bill No. 180
114	112
115	113
116		-	LCO 1486 {\\PRDFS1\SCOUSERS\FORZANOF\WS\2024SB-00180-
117		-	R01-SB.docx }
118		-	4 of 8
119	114
120		-	subsection. 78
	115	+	LCO No. 1486 4 of 8
	116	+
121	117		(4) For any utilization review for the treatment of a child or 79
122	118		adolescent mental disorder, the clinical review criteria used shall be: (A) 80
123	119		The most recent guidelines of the American Academy of Child and 81
124	120		Adolescent Psychiatry's Child and Adolescent Service Intensity 82
125	121		Instrument; or (B) clinical review criteria that the health carrier 83
126	122		demonstrates to the Insurance Department is consistent with the most 84
127	123		recent guidelines of the American Academy of Child and Adolescent 85
128	124		Psychiatry's Child and Adolescent Service Intensity Instrument, except 86
129	125		that nothing in this subdivision shall prohibit a health carrier from 87
130	126		developing its own clinical review criteria or purchasing or licensing 88
131	127		additional clinical review criteria from qualified vendors approved by 89
132	128		the commissioner, to address advancements in technology or types of 90
133	129		care for the treatment of a child or adolescent mental disorder, that are 91
134	130		not covered in the most recent guidelines of the American Academy of 92
135	131		Child and Adolescent Psychiatry's Child and Adolescent Service 93
136	132		Intensity Instrument. Any such clinical review criteria developed by a 94
137	133		health carrier or purchased or licensed from a qualified vendor shall 95
138	134		conform to the requirements of subparagraph (A) of subdivision (2) of 96
139	135		this subsection. 97
140	136		(5) For any utilization review for the treatment of an adult mental 98
141	137		disorder, the clinical review criteria used shall be: (A) The most recent 99
142	138		guidelines of the American Psychiatric Association or the most recent 100
143	139		Standards and Guidelines of the Association for Ambulatory Behavioral 101
144	140		Healthcare; or (B) clinical review criteria that the health carrier 102
145	141		demonstrates to the Insurance Department is consistent with the most 103
146	142		recent guidelines of the American Psychiatric Association or the most 104
147	143		recent Standards and Guidelines of the Association for Ambulatory 105
148	144		Behavioral Healthcare, except that nothing in this subdivision shall 106
149	145		prohibit a health carrier from developing its own clinical review criteria 107
150	146		or purchasing or licensing additional clinical review criteria from 108
151	147		qualified vendors approved by the commissioner, to address 109
152		-	advancements in technology or types of care for the treatment of an 110 Bill No. 180
	148	+	advancements in technology or types of care for the treatment of an 110
	149	+	adult mental disorder, that are not covered in the most recent guidelines 111
	150	+	of the American Psychiatric Association or the most recent Standards 112 Raised Bill No. 180
153	151
154	152
155		-	LCO 1486 {\\PRDFS1\SCOUSERS\FORZANOF\WS\2024SB-00180-
156		-	R01-SB.docx }
157		-	5 of 8
158	153
159		-	~~adult mental disorder,~~ ~~that are not covered in the most recent guidelines 111~~
160		-	~~of the American Psychiatric Association or the most recent Standards 112~~
	154	+	LCO No. 1486 5 of 8
	155	+
161	156		and Guidelines of the Association for Ambulatory Behavioral 113
162	157		Healthcare. Any such clinical review criteria developed by a health 114
163	158		carrier or purchased or licensed from a qualified vendor shall conform 115
164	159		to the requirements of subparagraph (A) of subdivision (2) of this 116
165	160		subsection. 117
166	161		Sec. 3. Subsection (a) of section 38a-591d of the 2024 supplement to 118
167	162		the general statutes is repealed and the following is substituted in lieu 119
168	163		thereof (Effective January 1, 2025): 120
169	164		(a) (1) Each health carrier shall maintain written procedures for (A) 121
170	165		utilization review and benefit determinations, (B) expedited utilization 122
171	166		review and benefit determinations with respect to prospective urgent 123
172	167		care requests and concurrent review urgent care requests, and (C) 124
173	168		notifying covered persons or covered persons ' authorized 125
174	169		representatives of such review and benefit determinations. Each health 126
175	170		carrier shall make such review and benefit determinations within the 127
176	171		specified time periods under this section. 128
177	172		(2) In determining whether a benefit request shall be considered an 129
178	173		urgent care request, an individual acting on behalf of a health carrier 130
179	174		shall apply the judgment of a prudent layperson who possesses an 131
180	175		average knowledge of health and medicine, except that any benefit 132
181	176		request (A) determined to be an urgent care request by a health care 133
182	177		professional with knowledge of the covered person's medical condition, 134
183	178		or (B) specified under subparagraph (B) or (C) of subdivision (38) of 135
184	179		section 38a-591a shall be deemed an urgent care request. 136
185	180		(3) (A) At the time a health carrier notifies a covered person, a covered 137
186	181		person's authorized representative or a covered person's health care 138
187	182		professional of an initial adverse determination that was based, in whole 139
188	183		or in part, on medical necessity, of a concurrent or prospective 140
189	184		utilization review or of a benefit request, the health carrier shall notify 141
190		-	the covered person's health care professional (i) of the opportunity for a 142 Bill No. 180
	185	+	the covered person's health care professional (i) of the opportunity for a 142
	186	+	conference as provided in subparagraph (B) of this subdivision, and (ii) 143
	187	+	that such conference shall not be considered a grievance of such initial 144 Raised Bill No. 180
191	188
192	189
193		-	LCO 1486 {\\PRDFS1\SCOUSERS\FORZANOF\WS\2024SB-00180-
194		-	R01-SB.docx }
195		-	6 of 8
196	190
197		-	~~conference as provided in subparagraph (B)~~ of ~~this subdivision, and (ii) 143~~
198		-	~~that such conference shall not be considered a grievance of such initial 144~~
	191	+	LCO No. 1486 6 of 8
	192	+
199	193		adverse determination as long as a grievance has not been filed as set 145
200	194		forth in subparagraph (B) of this subdivision. 146
201	195		(B) After a health carrier notifies a covered person, a covered person's 147
202	196		authorized representative or a covered person's health care professional 148
203	197		of an initial adverse determination that was based, in whole or in part, 149
204	198		on medical necessity, of a concurrent or prospective utilization review 150
205	199		or of a benefit request, the health carrier shall offer a covered person's 151
206	200		health care professional the opportunity to confer, at the request of the 152
207	201		covered person's health care professional, with a clinical peer of such 153
208	202		health carrier, provided such covered person, covered person's 154
209	203		authorized representative or covered person's health care professional 155
210	204		has not filed a grievance of such initial adverse determination prior to 156
211	205		such conference. Such conference shall not be considered a grievance of 157
212	206		such initial adverse determination. Such health carrier shall grant such 158
213	207		clinical peer the authority to reverse such initial adverse determination. 159
214	208		Sec. 4. Subsection (c) of section 38a-591e of the general statutes is 160
215	209		repealed and the following is substituted in lieu thereof (Effective January 161
216	210		1, 2025): 162
217	211		(c) (1) (A) When conducting a review of an adverse determination 163
218	212		under this section, the health carrier shall ensure that such review is 164
219	213		conducted in a manner to ensure the independence and impartiality of 165
220	214		the clinical peer or peers involved in making the review decision. 166
221	215		(B) If the adverse determination involves utilization review, the 167
222	216		health carrier shall designate an appropriate clinical peer or peers to 168
223	217		review such adverse determination. Such clinical peer or peers shall not 169
224	218		have been involved in the initial adverse determination. 170
225	219		(C) (i) For each review of an adverse determination under this section, 171
226	220		there shall be a rebuttable presumption that each health care service 172
227		-	under review is medically necessary if such health care service was 173 Bill No. 180
	221	+	under review is medically necessary if such health care service was 173
	222	+	ordered by a health care professional acting within the scope of the 174
	223	+	health care professional's practice. The health carrier may rebut such 175
	224	+	presumption by reasonably substantiating to the clinical peer or peers 176 Raised Bill No. 180
228	225
229	226
230		-	LCO 1486 {\\PRDFS1\SCOUSERS\FORZANOF\WS\2024SB-00180-
231		-	R01-SB.docx }
232		-	7 of 8
233	227
234		-	ordered by a health care professional acting within the scope of the 174
235		-	health care professional's practice. The health carrier may rebut such 175
236		-	presumption by reasonably substantiating to the clinical peer or peers 176
	228	+	LCO No. 1486 7 of 8
	229	+
237	230		conducting the review under this section that such health care service is 177
238	231		not medically necessary. 178
239	232		[(C)] (ii) The clinical peer or peers conducting a review under this 179
240	233		section shall take into consideration all comments, documents, records 180
241	234		and other information relevant to the covered person's benefit request 181
242	235		that is the subject of the adverse determination under review, that are 182
243	236		submitted by the covered person or the covered person's authorized 183
244	237		representative, regardless of whether such information was submitted 184
245	238		or considered in making the initial adverse determination. 185
246	239		(D) Prior to issuing a decision, the health carrier shall provide free of 186
247	240		charge, by facsimile, electronic means or any other expeditious method 187
248	241		available, to the covered person or the covered person's authorized 188
249	242		representative, as applicable, any new or additional documents, 189
250	243		communications, information and evidence relied upon and any new or 190
251	244		additional scientific or clinical rationale used by the health carrier in 191
252	245		connection with the grievance. Such documents, communications, 192
253	246		information, evidence and rationale shall be provided sufficiently in 193
254	247		advance of the date the health carrier is required to issue a decision to 194
255	248		permit the covered person or the covered person's authorized 195
256	249		representative, as applicable, a reasonable opportunity to respond prior 196
257	250		to such date. 197
258	251		(2) If the review under subdivision (1) of this subsection is an 198
259	252		expedited review, all necessary information, including the health 199
260	253		carrier's decision, shall be transmitted between the health carrier and the 200
261	254		covered person or the covered person's authorized representative, as 201
262	255		applicable, by telephone, facsimile, electronic means or any other 202
263	256		expeditious method available. 203
264	257		(3) If the review under subdivision (1) of this subsection is an 204
265		-	expedited review of a grievance involving an adverse determination of 205 Bill No. 180
	258	+	expedited review of a grievance involving an adverse determination of 205
	259	+	a concurrent review request, pursuant to 45 CFR 147.136, as amended 206
	260	+	from time to time, the treatment shall be continued without liability to 207
	261	+	the covered person until the covered person has been notified of the 208 Raised Bill No. 180
266	262
267	263
268		-	LCO 1486 {\\PRDFS1\SCOUSERS\FORZANOF\WS\2024SB-00180-
269		-	R01-SB.docx }
270		-	8 of 8
271	264
272		-	a concurrent review request, pursuant to 45 CFR 147.136, as amended 206
273		-	from time to time, the treatment shall be continued without liability to 207
274		-	the covered person until the covered person has been notified of the 208
	265	+	LCO No. 1486 8 of 8
	266	+
275	267		review decision. 209
276	268		This act shall take effect as follows and shall amend the following
277	269		sections:
278	270
279	271		Section 1 January 1, 2025 38a-591a(7)
280	272		Sec. 2 January 1, 2025 38a-591c(a)
281	273		Sec. 3 January 1, 2025 38a-591d(a)
282	274		Sec. 4 January 1, 2025 38a-591e(c)
283	275
284		-	PH Joint Favorable
	276	+	Statement of Purpose:
	277	+	To (1) redefine "clinical peer" for the purposes of adverse determination
	278	+	and utilization reviews; (2) require health carriers to bear the burden of
	279	+	proving that certain health care services under adverse determination
	280	+	or utilization review are not medically necessary; and (3) require health
	281	+	carriers to provide certain clinical peers with authority to reverse initial
	282	+	adverse determinations.
	283	+	[Proposed deletions are enclosed in brackets. Proposed additions are indicated by underline, except
	284	+	that when the entire text of a bill or resolution or a section of a bill or resolution is new, it is not
	285	+	underlined.]
285	286