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OLR Bill Analysis
sHB 7115
AN ACT CONCERNING REVISIONS TO THE HEALTH CARE COST
GROWTH BENCHMARK PROGRAM.
SUMMARY
This bill makes changes in laws related to payers’ (e.g., private health
insurers) annual reporting of aggregated data the Office of Health
Strategy (OHS) uses to calculate total health care expenditures, primary
care spending as a percentage of total medical expenses, and the net cost
of private health insurance in the state.
Specifically, the bill requires payers to include self-funded employee
health plan data in their annual data submission to OHS, if the employer
of the self-funded employee health plan completes an opt-in form,
which the commissioner must prescribe. Regarding the opt-in process,
the bill does the following:
1. generally requires payers to give employers the form within 15
days after the claim administration services are retained and
imposes a penalty for failing to do so;
2. keeps all completed opt-in forms in effect for all future data
reporting periods, but allows an employer to opt out by
providing written notice;
3. requires the payer to include, as part of its required data
submission, the self-funded health plan data for employers that
opted in; and
4. generally prohibits the payer from imposing a cost or fee on an
employer whose self-funded health benefit plan data is included
in the payer’s submission to the commissioner.
The bill also requires each payer, starting by January 31, 2026, to 2025HB-07115-R000472-BA.DOCX
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annually report to the commissioner specified information for the
preceding year, such as a list of the employers that opted in and a list of
those that opted out.
Existing law requires the OHS commissioner to hold annual
informational hearings that certain payers, provider entities, and other
entities must participate in. The bill (1) authorizes the commissioner to
specify how these entities must participate and (2) specifies that the
participant’s required testimony can be written and oral, as the
commissioner requests.
EFFECTIVE DATE: October 1, 2025
PAYER REPORTING REQU IREMENTS
Payer Defined
By law, a “payer” is an entity that, during a given calendar year, pays
health care providers for health care services or pharmacies or provider
entities for prescription drugs designated by the OHS commissioner. It
includes Medicaid, Medicare, governmental and nongovernment health
plans, and any organization acting as payer that is a subsidiary, affiliate,
or business owned or controlled by a payer (CGS § 19a-754f(9)).
Payer Annual Reporting Requirement
Existing law requires each payer to annually report to the OHS
commissioner certain aggregated data for the preceding year, including
for self-funded plans. The commissioner uses this data to calculate total
health care expenditures, primary care spending as a percentage of total
medical expenses, and the net cost of private health insurance.
The bill makes the changes below to this law as it pertains to
reporting self-funded health plan data.
Opt-in Form. Under the bill, each payer required to report data must
give employers with self-funded employee health plans a form that an
employer may complete to opt in to submitting its employee health plan
data to the payer, which the payer includes in its submission to OHS.
The opt-in form must be prescribed by the OHS commissioner and 2025HB-07115-R000472-BA.DOCX
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available on the office’s website. The bill allows the payer to use a form
developed for multistate use, if the commissioner determines that it is
substantially like the form she prescribes.
Penalty for Failure to Provide the Opt-in Form. The bill authorizes
the commissioner to impose a penalty on any payer that fails to give the
opt-in form to an employer with a self-funded employee health plan.
The penalty may be up to $10 per covered person enrolled in a self-
funded employee health plan.
Delivery and Effective Date. The payer must give the employer the
form within 15 days after the claim administration services are retained
and the payer determines that the employer satisfies the bill’s
requirements. A completed opt-in form is effective for the current data
reporting period and stays effective for all future data reporting periods
(unless the employer opts out, see below). Also, an employer cannot opt
in for a partial data reporting period.
Opting Out. An employer who opts in for a data reporting period
may opt out of all subsequent data reporting periods by providing
written notice at least 30 days before the next data reporting period
starts.
Reporting Self-Funded Health Plan Data. The payer must include
the self-funded health plan data as part of the payer’s required data
submission.
Payer’s Report to the OHS Commissioner
Starting by January 31, 2026, each payer must annually report to the
commissioner, in a form and manner she prescribes, the following for
the preceding year:
1. a list of self-funded employee health plans whose employer
opted in for submitting self-funded health plan data as described
above;
2. a list of employers who previously opted in for submitting the
data but subsequently opted out; 2025HB-07115-R000472-BA.DOCX
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3. a signed certification by a payer’s officer certifying that the payer
has taken reasonable efforts to give each employer the opt-in
form; and
4. a list identifying each employer, by name and mailing address,
to whom the payer gave the form.
Other Provisions
The bill specifies that the opt-in form can only be given to employers
with self-funded employee health plans. It also specifies that providing
the form in compliance with the bill does not affect any other required
reporting.
The bill generally prohibits any payer from imposing a cost or fee on
an employer whose self-funded data is included in the payer’s reporting
of aggregate data to the commissioner. However, the bill allows a payor
to impose the actual cost incurred for the data submission.
INFORMATIONAL PUBLIC HEARING
By law, the OHS commissioner must hold an informational public
hearing annually to compare the growth in total health care
expenditures in the performance year to the health care cost growth
benchmark (see BACKGROUND) for that year.
The bill authorizes the commissioner to specify how payers, provider
entities, and other entities (see below) participate in the informational
hearing.
The bill also requires the other entities that may be required to
participate in the hearing to provide written and oral testimony as the
commissioner requests.
Under existing law, the commissioner may require the following
persons to participate in the hearing:
1. payers and provider entities found to be significant contributors
to healthcare cost growth in the state for the performance year, or
that failed to meet the primary care spending target, and 2025HB-07115-R000472-BA.DOCX
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2. any other entity found to be a significant contributor to health
care cost growth in the state during the performance year.
By law, an “other entity” is a drug manufacturer, pharmacy benefits
manager, or other health care provider that is not a provider entity (CGS
§ 19a-754f(8)). A “provider entity” is an organized group of clinicians
that (1) come together for contracting purposes or (2) are an established
billing unit that at least includes primary care providers, and that
collectively, during any given calendar year, has enough attributed lives
to participate in total cost of care contracts, even if they are not engaged
in a total cost of care contract (CGS § 19a-754f(13)).
BACKGROUND
Healthcare Cost Benchmark
By law, the OHS commissioner must publish on the office’s Internet
web site the (1) health care cost growth benchmarks and annual primary
care spending targets as a percentage of total medical expenses for the
calendar years 2021 to 2025, inclusive, and (2) annual health care quality
benchmarks for the calendar years 2022 to 2025, inclusive.
By July 1, 2025, and every five years after that, the commissioner must
develop and adopt annual health care cost growth benchmarks and
annual primary care spending targets for the following five calendar
years for provider entities and payers (CGS § 19a-754g).
COMMITTEE ACTION
Insurance and Real Estate Committee
Joint Favorable Substitute
Yea 13 Nay 0 (03/13/2025)