LCO 1 of 26
General Assembly Substitute Bill No. 10
January Session, 2025
AN ACT CONCERNING HEALTH INSURANCE AND PATIENT
PROTECTION.
Be it enacted by the Senate and House of Representatives in General
Assembly convened:
Section 1. (NEW) (Effective October 1, 2025) (a) As used in this section: 1
(1) "Health carrier" has the same meaning as provided in section 38a-2
1080 of the general statutes; and 3
(2) "Mental health and substance use disorder benefits" has the same 4
meaning as provided in section 38a-477ee of the general statutes, as 5
amended by this act. 6
(b) (1) Not later than March 1, 2026, and annually thereafter, each 7
health carrier shall file a certification with the Insurance Commissioner 8
for the immediately preceding calendar year, certifying that such health 9
carrier completed a review of such health carrier's administrative 10
practices for compliance with the state and federal mental health and 11
substance use disorder benefit reporting requirements pursuant to 12
sections 38a-477ee, as amended by this act, 38a-488c, 38a-488d, 38a-514c, 13
38a-514d, 38a-488a, 38a-514, 38a-510, as amended by this act, and 38a-14
544 of the general statutes, as amended by this act, and the provisions 15
of the federal Paul Wellstone and Pete Domenici Mental Health Parity 16
and Addiction Equity Act of 2008, P.L. 110-343, as amended from time 17 Substitute Bill No. 10
LCO 2 of 26
to time, and regulations adopted thereunder. Such certification shall be 18
signed by the chief executive officer and chief medical officer of such 19
health carrier. 20
(2) If such health carrier determines that such health carrier's 21
administrative practices for the immediately preceding calendar year 22
comply with the state and federal mental health and substance use 23
disorder benefit reporting requirements identified in subdivision (1) of 24
this subsection, such certification filed pursuant to subdivision (1) of this 25
subsection shall state such finding. 26
(3) If such health carrier determines that such health carrier's 27
administrative practices for the immediately preceding calendar year 28
fail to comply with the state and federal mental health and substance 29
use disorder benefit reporting requirements identified in subdivision (1) 30
of this subsection, such certification filed pursuant to subdivision (1) of 31
this subsection shall state such finding and identify (A) each 32
administrative practice of such health carrier not in compliance with 33
such state and federal mental health and substance use disorder benefit 34
reporting requirements, and (B) action that such health carrier will take 35
to bring such health carrier's administrative practices into compliance 36
with such state and federal mental health and substance use disorder 37
benefit reporting requirements. 38
Sec. 2. Subsection (c) of section 38a-477ee of the general statutes is 39
repealed and the following is substituted in lieu thereof (Effective October 40
1, 2025): 41
(c) [(1)] Not later than April 15, 2021, and annually thereafter, the 42
Insurance Commissioner shall submit each report that the 43
commissioner received pursuant to subsection (b) of this section for the 44
calendar year immediately preceding to: 45
[(A)] (1) The joint standing committee of the General Assembly 46
having cognizance of matters relating to insurance, in accordance with 47
section 11-4a; and 48 Substitute Bill No. 10
LCO 3 of 26
[(B)] (2) The Attorney General, Healthcare Advocate and 49
Commissioner of Health Strategy. 50
[(2) Notwithstanding subdivision (1) of this subsection, the 51
commissioner shall not submit the name or identity of any health carrier 52
or entity that has contracted with such health carrier, and such name or 53
identity shall be given confidential treatment and not be made public by 54
the commissioner.] 55
Sec. 3. (NEW) (Effective from passage) There is established an account 56
to be known as the "parity advancement account" which shall be a 57
separate, nonlapsing account within the General Fund. The account 58
shall contain any moneys required by law to be deposited in the account 59
and may receive donations from public or private sources. Moneys in 60
the account shall be expended by the Insurance Department, beginning 61
with the fiscal year ending June 30, 2026, for the purposes of enforcing 62
the state and federal mental health and substance use disorder benefit 63
reporting requirements identified in subdivision (1) of subsection (b) of 64
section 1 of this act, conducting consumer education and other 65
initiatives that support mental health parity implementation and 66
enforcement on behalf of consumers. 67
Sec. 4. (NEW) (Effective October 1, 2025) (a) (1) The commissioner, after 68
providing an opportunity for a hearing in accordance with chapter 54 of 69
the general statutes, may impose a civil penalty on any health carrier of 70
not more than one hundred dollars with respect to each participant or 71
beneficiary covered under a health insurance policy of such health 72
carrier, provided such penalty shall not exceed an aggregate amount of 73
one million dollars annually, for such health carrier's failure to comply 74
with the certification requirements pursuant to the provisions of section 75
1 of this act, or the state and federal mental health and substance use 76
disorder benefit reporting requirements identified in subdivision (1) of 77
subsection (b) of section 1 of this act. 78
(2) The commissioner may order the payment of such reasonable 79
expenses as may be necessary to compensate the commissioner in 80 Substitute Bill No. 10
LCO 4 of 26
conjunction with any proceedings under this section, which shall be 81
dedicated to the enforcement and implementation of the state and 82
federal mental health parity laws and regulations adopted thereunder. 83
(b) (1) If any health carrier fails to file any data, report, certification or 84
other information required by the provisions of section 38a-477ee of the 85
general statutes, as amended by this act, or section 1 of this act, the 86
commissioner shall impose a late fee on such health carrier of one 87
hundred dollars per day from the due date of such filing of data, report, 88
certification or information to the date such health carrier submits such 89
filing to the commissioner. 90
(2) For any health carrier that files any incomplete data, report, 91
certification or other information required by the provisions of section 92
38a-477ee of the general statutes, as amended by this act, and section 1 93
of this act, the commissioner shall provide notice to such health carrier 94
of such incomplete filing that includes (A) a description of such data, 95
report, certification or other information that is incomplete and any 96
additional data that is needed to consider such filing complete, and (B) 97
the date by which such health carrier is required to provide such data. 98
The commissioner shall impose a late fee on such health carrier of one 99
hundred dollars per day, commencing from the date identified by the 100
commissioner pursuant to subparagraph (B) of this subdivision. 101
(c) The commissioner may waive any civil penalty imposed pursuant 102
to subsection (a) of this section if the commissioner determines that the 103
violation was due to reasonable cause and was not due to wilful neglect, 104
or if such violation is corrected not more than thirty days after the date 105
that the health carrier filed a certification of noncompliance with the 106
commissioner pursuant to section 1 of this act. 107
(d) All civil penalties and late fees received by the commissioner 108
pursuant to this section shall be deposited in the General Fund and 109
credited to the parity advancement account established pursuant to 110
section 3 of this act. 111
Sec. 5. Subsections (a) and (b) of section 38a-591c of the general 112 Substitute Bill No. 10
LCO 5 of 26
statutes are repealed and the following is substituted in lieu thereof 113
(Effective January 1, 2026): 114
(a) (1) Each health carrier shall contract with (A) health care 115
professionals to administer such health carrier's utilization review 116
program, and (B) clinical peers to evaluate the clinical appropriateness 117
of an adverse determination. 118
(2) (A) Each utilization review program shall use documented clinical 119
review criteria that are based on sound clinical evidence and are 120
evaluated periodically by the health carrier's organizational mechanism 121
specified in subparagraph (F) of subdivision (2) of subsection (c) of 122
section 38a-591b to [assure] ensure such program's ongoing 123
effectiveness. 124
(B) Except as provided in subdivisions (3), (4) and (5) of this 125
subsection, a health carrier may develop its own clinical review criteria 126
or it may purchase or license clinical review criteria from qualified 127
vendors approved by the commissioner, provided such clinical review 128
criteria conform to the requirements of subparagraph (A) of this 129
subdivision. 130
(C) Each health carrier shall (i) post on its Internet web site (I) any 131
clinical review criteria it uses, and (II) links to any rule, guideline, 132
protocol or other similar criterion a health carrier may rely upon to make 133
an adverse determination as described in subparagraph (F) of 134
subdivision (1) of subsection (e) of section 38a-591d, and (ii) make its 135
clinical review criteria available upon request to authorized government 136
agencies. 137
(D) For each utilization review, there shall be a rebuttable 138
presumption that each health care service under review is medically 139
necessary if such health care service was ordered by a health care 140
professional acting within such health care professional's scope of 141
practice. Any utilization review company performing such review of a 142
health care service shall have the burden of proving that such health 143
care service is not medically necessary. 144 Substitute Bill No. 10
LCO 6 of 26
(3) For any utilization review for the treatment of a substance use 145
disorder, as described in section 17a-458, the clinical review criteria used 146
shall be: (A) The most recent edition of the American Society of 147
Addiction Medicine Treatment Criteria for Addictive, Substance-148
Related, and Co-Occurring Conditions; or (B) clinical review criteria that 149
the health carrier demonstrates to the Insurance Department is 150
consistent with the most recent edition of the American Society of 151
Addiction Medicine Treatment Criteria for Addictive, Substance-152
Related, and Co-Occurring Conditions, except that nothing in this 153
subdivision shall prohibit a health carrier from developing its own 154
clinical review criteria or purchasing or licensing additional clinical 155
review criteria from qualified vendors approved by the commissioner, 156
to address advancements in technology or types of care for the 157
treatment of a substance use disorder, that are not covered in the most 158
recent edition of the American Society of Addiction Medicine Treatment 159
Criteria for Addictive, Substance-Related, and Co-Occurring 160
Conditions. Any such clinical review criteria developed by a health 161
carrier or purchased or licensed from a qualified vendor shall conform 162
to the requirements of subparagraph (A) of subdivision (2) of this 163
subsection. 164
(4) For any utilization review for the treatment of a child or 165
adolescent mental disorder, the clinical review criteria used shall be: (A) 166
The most recent guidelines of the American Academy of Child and 167
Adolescent Psychiatry's Child and Adolescent Service Intensity 168
Instrument; or (B) clinical review criteria that the health carrier 169
demonstrates to the Insurance Department is consistent with the most 170
recent guidelines of the American Academy of Child and Adolescent 171
Psychiatry's Child and Adolescent Service Intensity Instrument, except 172
that nothing in this subdivision shall prohibit a health carrier from 173
developing its own clinical review criteria or purchasing or licensing 174
additional clinical review criteria from qualified vendors approved by 175
the commissioner, to address advancements in technology or types of 176
care for the treatment of a child or adolescent mental disorder, that are 177
not covered in the most recent guidelines of the American Academy of 178 Substitute Bill No. 10
LCO 7 of 26
Child and Adolescent Psychiatry's Child and Adolescent Service 179
Intensity Instrument. Any such clinical review criteria developed by a 180
health carrier or purchased or licensed from a qualified vendor shall 181
conform to the requirements of subparagraph (A) of subdivision (2) of 182
this subsection. 183
(5) For any utilization review for the treatment of an adult mental 184
disorder, the clinical review criteria used shall be: (A) The most recent 185
guidelines of the American Psychiatric Association or the most recent 186
Standards and Guidelines of the Association for Ambulatory Behavioral 187
Healthcare; or (B) clinical review criteria that the health carrier 188
demonstrates to the Insurance Department is consistent with the most 189
recent guidelines of the American Psychiatric Association or the most 190
recent Standards and Guidelines of the Association for Ambulatory 191
Behavioral Healthcare, except that nothing in this subdivision shall 192
prohibit a health carrier from developing its own clinical review criteria 193
or purchasing or licensing additional clinical review criteria from 194
qualified vendors approved by the commissioner, to address 195
advancements in technology or types of care for the treatment of an 196
adult mental disorder, that are not covered in the most recent guidelines 197
of the American Psychiatric Association or the most recent Standards 198
and Guidelines of the Association for Ambulatory Behavioral 199
Healthcare. Any such clinical review criteria developed by a health 200
carrier or purchased or licensed from a qualified vendor shall conform 201
to the requirements of subparagraph (A) of subdivision (2) of this 202
subsection. 203
(b) Each health carrier shall: 204
(1) Have procedures in place to ensure that (A) the health care 205
professionals administering such health carrier's utilization review 206
program are applying the clinical review criteria consistently in 207
utilization review determinations, and (B) the appropriate or required 208
individual or individuals are being designated to conduct utilization 209
reviews; 210 Substitute Bill No. 10
LCO 8 of 26
(2) Have data systems sufficient to support utilization review 211
program activities and to generate management reports to enable the 212
health carrier to monitor and manage health care services effectively; 213
(3) Provide covered persons and participating providers with access 214
to its utilization review staff through a toll-free telephone number or 215
any other free calling option or by electronic means; 216
(4) Coordinate the utilization review program with other medical 217
management activity conducted by the health carrier, such as quality 218
assurance, credentialing, contracting with health care professionals, 219
data reporting, grievance procedures, processes for assessing member 220
satisfaction and risk management; [and] 221
(5) Routinely assess the effectiveness and efficiency of its utilization 222
review program; and 223
(6) Not use any system that employs artificial intelligence, as defined 224
in section 51-10e, or any other algorithm in lieu of a review by a clinical 225
peer to evaluate the clinical appropriateness of an adverse 226
determination pursuant to a contract between such clinical peer and 227
such health carrier. 228
Sec. 6. Subsection (c) of section 38a-591e of the general statutes is 229
repealed and the following is substituted in lieu thereof (Effective January 230
1, 2026): 231
(c) (1) (A) When conducting a review of an adverse determination 232
under this section, the health carrier shall ensure that such review is 233
conducted in a manner to ensure the independence and impartiality of 234
the clinical peer or peers involved in making the review decision. 235
(B) If the adverse determination involves utilization review, the 236
health carrier shall designate an appropriate clinical peer or peers to 237
review such adverse determination. Such clinical peer or peers shall not 238
have been involved in the initial adverse determination. 239
(C) (i) To effectuate the rebuttable presumption pursuant to 240 Substitute Bill No. 10
LCO 9 of 26
subparagraph (D) of subdivision (2) of subsection (a) of section 38a-591c, 241
as amended by this act, the health carrier may rebut such presumption 242
by reasonably substantiating to the clinical peer or peers conducting the 243
review pursuant to the provisions of this section that such health care 244
service is not medically necessary. 245
[(C)] (ii) The clinical peer or peers conducting a review under this 246
section shall take into consideration all comments, documents, records 247
and other information relevant to the covered person's benefit request 248
that is the subject of the adverse determination under review, that are 249
submitted by the covered person or the covered person's authorized 250
representative, regardless of whether such information was submitted 251
or considered in making the initial adverse determination. 252
(D) Prior to issuing a decision, the health carrier shall provide free of 253
charge, by facsimile, electronic means or any other expeditious method 254
available, to the covered person or the covered person's authorized 255
representative, as applicable, any new or additional documents, 256
communications, information and evidence relied upon and any new or 257
additional scientific or clinical rationale used by the health carrier in 258
connection with the grievance. Such documents, communications, 259
information, evidence and rationale shall be provided sufficiently in 260
advance of the date the health carrier is required to issue a decision to 261
permit the covered person or the covered person's authorized 262
representative, as applicable, a reasonable opportunity to respond prior 263
to such date. 264
(2) If the review under subdivision (1) of this subsection is an 265
expedited review, all necessary information, including the health 266
carrier's decision, shall be transmitted between the health carrier and the 267
covered person or the covered person's authorized representative, as 268
applicable, by telephone, facsimile, electronic means or any other 269
expeditious method available. 270
(3) If the review under subdivision (1) of this subsection is an 271
expedited review of a grievance involving an adverse determination of 272 Substitute Bill No. 10
LCO 10 of 26
a concurrent review request, pursuant to 45 CFR 147.136, as amended 273
from time to time, the treatment shall be continued without liability to 274
the covered person until the covered person has been notified of the 275
review decision. 276
Sec. 7. Section 38a-510 of the general statutes is repealed and the 277
following is substituted in lieu thereof (Effective January 1, 2026): 278
(a) No insurance company, hospital service corporation, medical 279
service corporation, health care center or other entity delivering, issuing 280
for delivery, renewing, amending or continuing an individual health 281
insurance policy or contract that provides coverage for prescription 282
drugs may: 283
(1) Require any person covered under such policy or contract to 284
obtain prescription drugs from a mail order pharmacy as a condition of 285
obtaining benefits for such drugs; or 286
(2) Require, if such insurance company, hospital service corporation, 287
medical service corporation, health care center or other entity uses step 288
therapy for such drugs, the use of step therapy (A) for any prescribed 289
drug for longer than [thirty] twenty days, (B) for a prescribed drug for 290
[cancer treatment for an insured who has been diagnosed with stage IV 291
metastatic cancer] the treatment of a disabling or life-threatening 292
chronic disease or condition, provided such prescribed drug is in 293
compliance with approved federal Food and Drug Administration 294
indications, [or] (C) for the period commencing January 1, 2024, and 295
ending January 1, 2027, inclusive, for the treatment of schizophrenia, 296
major depressive disorder or bipolar disorder, as defined in the most 297
recent edition of the American Psychiatric Association's "Diagnostic and 298
Statistical Manual of Mental Disorders", or (D) for a prescribed drug for 299
the treatment of a mental or behavioral health condition, provided such 300
prescribed drug is in compliance with approved federal Food and Drug 301
Administration indications. 302
(3) At the expiration of the time period specified in subparagraph (A) 303
of subdivision (2) of this subsection or for a prescribed drug described 304 Substitute Bill No. 10
LCO 11 of 26
in [subparagraph (B) or (C)] subparagraphs (B) to (D), inclusive, of 305
subdivision (2) of this subsection, an insured's treating health care 306
provider may deem such step therapy drug regimen clinically 307
ineffective for the insured, at which time the insurance company, 308
hospital service corporation, medical service corporation, health care 309
center or other entity shall authorize dispensation of and coverage for 310
the drug prescribed by the insured's treating health care provider, 311
provided such drug is a covered drug under such policy or contract. If 312
such provider does not deem such step therapy drug regimen clinically 313
ineffective or has not requested an override pursuant to subdivision (1) 314
of subsection (b) of this section, such drug regimen may be continued. 315
For purposes of this section, "step therapy" means a protocol or program 316
that establishes the specific sequence in which prescription drugs for a 317
specified medical condition are to be prescribed. 318
(b) (1) Notwithstanding the [sixty-day] twenty-day period set forth 319
in subparagraph (A) of subdivision (2) of subsection (a) of this section, 320
each insurance company, hospital service corporation, medical service 321
corporation, health care center or other entity that uses step therapy for 322
such prescription drugs shall establish and disclose to its health care 323
providers a process by which an insured's treating health care provider 324
may request at any time an override of the use of any step therapy drug 325
regimen. Any such override process shall be convenient to use by health 326
care providers and an override request shall be expeditiously granted 327
when an insured's treating health care provider demonstrates that the 328
drug regimen required under step therapy (A) has been ineffective in 329
the past for treatment of the insured's medical condition, (B) is expected 330
to be ineffective based on the known relevant physical or mental 331
characteristics of the insured and the known characteristics of the drug 332
regimen, (C) will cause or will likely cause an adverse reaction by or 333
physical harm to the insured, or (D) is not in the best interest of the 334
insured, based on medical necessity. 335
(2) Upon the granting of an override request, the insurance company, 336
hospital service corporation, medical service corporation, health care 337
center or other entity shall authorize dispensation of and coverage for 338 Substitute Bill No. 10
LCO 12 of 26
the drug prescribed by the insured's treating health care provider, 339
provided such drug is a covered drug under such policy or contract. 340
(c) Nothing in this section shall (1) preclude an insured or an 341
insured's treating health care provider from requesting a review under 342
sections 38a-591c to 38a-591g, inclusive, as amended by this act, or (2) 343
affect the provisions of section 38a-492i. 344
Sec. 8. Section 38a-544 of the general statutes is repealed and the 345
following is substituted in lieu thereof (Effective January 1, 2026): 346
(a) No insurance company, hospital service corporation, medical 347
service corporation, health care center or other entity delivering, issuing 348
for delivery, renewing, amending or continuing a group health 349
insurance policy or contract that provides coverage for prescription 350
drugs may: 351
(1) Require any person covered under such policy or contract to 352
obtain prescription drugs from a mail order pharmacy as a condition of 353
obtaining benefits for such drugs; or 354
(2) Require, if such insurance company, hospital service corporation, 355
medical service corporation, health care center or other entity uses step 356
therapy for such drugs, the use of step therapy (A) for any prescribed 357
drug for longer than [thirty] twenty days, (B) for a prescribed drug for 358
[cancer treatment for an insured who has been diagnosed with stage IV 359
metastatic cancer] the treatment of a disabling or life-threatening 360
chronic disease or condition, provided such prescribed drug is in 361
compliance with approved federal Food and Drug Administration 362
indications, [or] (C) for the period commencing January 1, 2024, and 363
ending January 1, 2027, inclusive, for the treatment of schizophrenia, 364
major depressive disorder or bipolar disorder, as defined in the most 365
recent edition of the American Psychiatric Association's "Diagnostic and 366
Statistical Manual of Mental Disorders", or (D) for a prescribed drug for 367
the treatment of a mental or behavioral health condition, provided such 368
prescribed drug is in compliance with approved federal Food and Drug 369
Administration indications. 370 Substitute Bill No. 10
LCO 13 of 26
(3) At the expiration of the time period specified in subparagraph (A) 371
of subdivision (2) of this subsection or for a prescribed drug described 372
in [subparagraph (B) or (C)] subparagraphs (B) to (D), inclusive, of 373
subdivision (2) of this subsection, an insured's treating health care 374
provider may deem such step therapy drug regimen clinically 375
ineffective for the insured, at which time the insurance company, 376
hospital service corporation, medical service corporation, health care 377
center or other entity shall authorize dispensation of and coverage for 378
the drug prescribed by the insured's treating health care provider, 379
provided such drug is a covered drug under such policy or contract. If 380
such provider does not deem such step therapy drug regimen clinically 381
ineffective or has not requested an override pursuant to subdivision (1) 382
of subsection (b) of this section, such drug regimen may be continued. 383
For purposes of this section, "step therapy" means a protocol or program 384
that establishes the specific sequence in which prescription drugs for a 385
specified medical condition are to be prescribed. 386
(b) (1) Notwithstanding the [sixty-day] twenty-day period set forth 387
in subparagraph (A) of subdivision (2) of subsection (a) of this section, 388
each insurance company, hospital service corporation, medical service 389
corporation, health care center or other entity that uses step therapy for 390
such prescription drugs shall establish and disclose to its health care 391
providers a process by which an insured's treating health care provider 392
may request at any time an override of the use of any step therapy drug 393
regimen. Any such override process shall be convenient to use by health 394
care providers and an override request shall be expeditiously granted 395
when an insured's treating health care provider demonstrates that the 396
drug regimen required under step therapy (A) has been ineffective in 397
the past for treatment of the insured's medical condition, (B) is expected 398
to be ineffective based on the known relevant physical or mental 399
characteristics of the insured and the known characteristics of the drug 400
regimen, (C) will cause or will likely cause an adverse reaction by or 401
physical harm to the insured, or (D) is not in the best interest of the 402
insured, based on medical necessity. 403
(2) Upon the granting of an override request, the insurance company, 404 Substitute Bill No. 10
LCO 14 of 26
hospital service corporation, medical service corporation, health care 405
center or other entity shall authorize dispensation of and coverage for 406
the drug prescribed by the insured's treating health care provider, 407
provided such drug is a covered drug under such policy or contract. 408
(c) Nothing in this section shall (1) preclude an insured or an 409
insured's treating health care provider from requesting a review under 410
sections 38a-591c to 38a-591g, inclusive, as amended by this act, or (2) 411
affect the provisions of section 38a-518i. 412
Sec. 9 (NEW) (Effective July 1, 2026) (a) Each insurer, health care 413
center, hospital service corporation, medical service corporation, 414
preferred provider network or other entity that enters into, renews or 415
amends a contract with a health care provider on or after July 1, 2026, to 416
provide covered benefits to insureds or enrollees in this state shall 417
include in such contract: 418
(1) A provision requiring such insurer, health care center, hospital 419
service corporation, medical service corporation, preferred provider 420
network or other entity to: 421
(A) Reimburse the contracting health care provider for a covered 422
outpatient benefit that uses a current procedural terminology 423
evaluation and management (CPT E/M) code, current procedural 424
terminology assessment and management (CPT A/M) code or drug 425
infusion code in an amount that does not vary based on the facility 426
where the contracting health care provider provides such benefit; and 427
(B) Use equal reimbursement rates for all contracting health care 428
providers in the same geographic region, as determined by the 429
Insurance Commissioner, in accordance with the provisions of chapter 430
54 of the general statutes, and regardless of the employer or affiliation 431
of any contracting health care provider, for each covered outpatient 432
benefit described in subparagraph (A) of this subdivision if the 433
reimbursement for such covered outpatient benefit is made on a fee-for-434
benefit basis or on the basis of bundled benefits per diagnosis, condition, 435
procedure or another standardized bundle of health care benefits; and 436 Substitute Bill No. 10
LCO 15 of 26
(2) A conspicuous statement that such contract complies with the 437
provisions of subdivision (1) of this subsection. 438
(b) The Insurance Commissioner shall adopt regulations, in 439
accordance with the provisions of chapter 54 of the general statutes, to 440
implement the provisions of this section, including, but not limited to, 441
the establishment of geographic regions pursuant to the provisions of 442
subparagraph (B) of subdivision (1) of subsection (a) of this section. 443
Sec. 10. Subsections (a) to (c), inclusive, of section 38a-481 of the 444
general statutes are repealed and the following is substituted in lieu 445
thereof (Effective January 1, 2026): 446
(a) No individual health insurance policy shall be delivered or issued 447
for delivery to any person in this state, nor shall any application, rider 448
or endorsement be used in connection with such policy, until a copy of 449
the form thereof and of the classification of risks and the premium rates 450
have been filed with the commissioner. Rate filings shall include the 451
information and data required under section 38a-479qqq if the policy is 452
subject to said section, and an actuarial memorandum that includes, but 453
is not limited to, pricing assumptions and claims experience, the 454
requirements established in section 15 of this act, and premium rates 455
and loss ratios from the inception of the policy. Each premium rate filed 456
on or after January 1, 2021, shall, if the insurer intends to account for 457
rebates, as defined in section 38a-479ooo in the manner specified in 458
section 38a-479rrr, account for such rebates in such manner, if the policy 459
is subject to section 38a-479rrr. The commissioner may adopt 460
regulations, in accordance with the provisions of chapter 54, to establish 461
a procedure for reviewing such policies. The commissioner shall 462
disapprove the use of such form at any time if it does not comply with 463
the requirements of law, or if it contains a provision or provisions that 464
are unfair or deceptive or that encourage misrepresentation of the 465
policy. The commissioner shall notify, in writing, the insurer that has 466
filed any such form of the commissioner's disapproval, specifying the 467
reasons for disapproval, and ordering that no such insurer shall deliver 468
or issue for delivery to any person in this state a policy on or containing 469 Substitute Bill No. 10
LCO 16 of 26
such form. The provisions of section 38a-19 shall apply to such orders. 470
As used in this subsection, "loss ratio" means the ratio of incurred claims 471
to earned premiums by the number of years of policy duration for all 472
combined durations. 473
(b) (1) No rate filed under the provisions of subsection (a) of this 474
section shall be effective until it has been approved by the commissioner 475
in accordance with regulations adopted pursuant to this subsection. The 476
commissioner shall adopt regulations, in accordance with the 477
provisions of chapter 54, to prescribe standards to ensure that such rates 478
shall not be excessive, inadequate, [or] unfairly discriminatory [. The 479
commissioner may disapprove such rate if it fails to comply with such 480
standards, except that no rate filed under the provisions of subsection 481
(a) of this section for any Medicare supplement policy shall be effective 482
unless approved in accordance with section 38a-474] or unaffordable 483
pursuant to the provisions of section 15 of this act. 484
(2) Any rate filed in accordance with the provisions of subsection (a) 485
of this section for health insurance that provides coverage of the type 486
specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 shall 487
be approved in accordance with the provisions of section 15 of this act. 488
(c) (1) No rate filed in accordance with the provisions of subsection 489
(a) of this section for any Medicare supplement policy shall be effective 490
unless approved in accordance with the provisions of section 38a-474. 491
[(c)] (2) No insurance company, fraternal benefit society, hospital 492
service corporation, medical service corporation, health care center or 493
other entity that delivers or issues for delivery in this state any Medicare 494
supplement policies or certificates shall incorporate in its rates or 495
determinations to grant coverage for Medicare supplement insurance 496
policies or certificates any factors or values based on the age, gender, 497
previous claims history or the medical condition of any person covered 498
by such policy or certificate. 499
Sec. 11. Section 38a-513 of the general statutes is repealed and the 500
following is substituted in lieu thereof (Effective January 1, 2026): 501 Substitute Bill No. 10
LCO 17 of 26
(a) [(1)] No group health insurance policy, as defined by the 502
commissioner, or certificate shall be delivered or issued for delivery in 503
this state unless a copy of the form for such policy or certificate has been 504
submitted to and approved by the commissioner under the regulations 505
adopted pursuant to this section. The commissioner shall adopt 506
regulations, in accordance with the provisions of chapter 54, concerning 507
the provisions, submission and approval of such policies and certificates 508
and establishing a procedure for reviewing such policies and 509
certificates. The commissioner shall disapprove the use of such form at 510
any time if it does not comply with the requirements of law, or if it 511
contains a provision or provisions that are unfair or deceptive or that 512
encourage misrepresentation of the policy. The commissioner shall 513
notify, in writing, the insurer that has filed any such form of the 514
commissioner's disapproval, specifying the reasons for disapproval, 515
and ordering that no such insurer shall deliver or issue for delivery to 516
any person in this state a policy on or containing such form. The 517
provisions of section 38a-19 shall apply to such order. 518
(b) (1) No rate filed in accordance with the provisions of subsection 519
(a) of this section shall be effective until such rate has been approved by 520
the commissioner in accordance with regulations adopted pursuant to 521
this subsection or as provided under subdivision (2) of this subsection. 522
The commissioner shall adopt regulations, in accordance with the 523
provisions of chapter 54, to prescribe standards to ensure that such rates 524
shall not be excessive, inadequate, unfairly discriminatory or 525
unaffordable pursuant to the provisions of section 15 of this act. 526
(2) Any rate filed in accordance with the provisions of subsection (a) 527
of this section for a group health insurance policy that provides 528
coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) 529
of section 38a-469 shall be approved in accordance with the provisions 530
of section 15 of this act. 531
[(2)] (c) No group health insurance policy or certificate for a small 532
employer, as defined in section 38a-564, shall be delivered or issued for 533
delivery in this state unless the premium rates have been submitted to 534 Substitute Bill No. 10
LCO 18 of 26
and approved by the commissioner in accordance with the provisions 535
of section 15 of this act. Premium rate filings shall include the 536
information and data required under section 38a-479qqq if the policy is 537
subject to said section, and an actuarial memorandum that includes, but 538
is not limited to, pricing assumptions and claims experience, the 539
requirements set forth in section 15 of this act, and premium rates and 540
loss ratios from the inception of the policy. Each premium rate filed on 541
or after January 1, 2021, shall, if the insurer intends to account for 542
rebates, as defined in section 38a-479ooo in the manner specified in 543
section 38a-479rrr, account for such rebates in such manner, if the policy 544
is subject to section 38a-479rrr. As used in this subdivision, "loss ratio" 545
means the ratio of incurred claims to earned premiums by the number 546
of years of policy duration for all combined durations. 547
[(b)] (d) No insurance company, fraternal benefit society, hospital 548
service corporation, medical service corporation, health care center or 549
other entity that delivers or issues for delivery in this state any Medicare 550
supplement policies or certificates shall incorporate in its rates or 551
determinations to grant coverage for Medicare supplement insurance 552
policies or certificates any factors or values based on the age, gender, 553
previous claims history or the medical condition of any person covered 554
by such policy or certificate. 555
[(c)] (e) Nothing in this chapter shall preclude the issuance of a group 556
health insurance policy that includes an optional life insurance rider, 557
provided the optional life insurance rider shall be filed with and 558
approved by the Insurance Commissioner pursuant to section 38a-430. 559
Any company offering such policies for sale in this state shall be licensed 560
to sell life insurance in this state pursuant to the provisions of section 561
38a-41. 562
[(d)] (f) Not later than January 1, 2009, the commissioner shall adopt 563
regulations, in accordance with chapter 54, to establish minimum 564
standards for benefits in group specified disease policies, certificates, 565
riders, endorsements and benefits. 566 Substitute Bill No. 10
LCO 19 of 26
Sec. 12. Subdivision (1) of subsection (a) of section 38a-183 of the 567
general statutes is repealed and the following is substituted in lieu 568
thereof (Effective January 1, 2026): 569
(a) (1) A health care center governed by sections 38a-175 to 38a-194, 570
inclusive, shall not enter into any agreement with subscribers unless and 571
until [it] such health care center has filed with the commissioner a full 572
schedule of the amounts to be paid by the subscribers and has obtained 573
the commissioner's approval [thereof] in accordance with the provisions 574
of section 15 of this act. Such filing shall include the information and 575
data required under section 38a-479qqq if the contract or policy is 576
subject to said section, and an actuarial memorandum that includes, but 577
is not limited to, pricing assumptions and claims experience, and 578
premium rates and loss ratios from the inception of the contract or 579
policy. The commissioner [may refuse such approval if the 580
commissioner finds such amounts to] shall adopt regulations, in 581
accordance with the provisions of chapter 54, to prescribe standards to 582
ensure that such amounts shall not be excessive, inadequate, [or] 583
discriminatory or unaffordable pursuant to the provisions of section 15 584
of this act. As used in this subsection, "loss ratio" means the ratio of 585
incurred claims to earned premiums by the number of years of policy 586
duration for all combined durations. 587
Sec. 13. Subsection (a) of section 38a-208 of the general statutes is 588
repealed and the following is substituted in lieu thereof (Effective January 589
1, 2026): 590
(a) No such corporation shall enter into any contract with subscribers 591
unless and until it has filed with the Insurance Commissioner a full 592
schedule of the rates to be paid by the subscribers and has obtained said 593
commissioner's approval [thereof] in accordance with the provisions of 594
section 15 of this act. Such filing shall include an actuarial memorandum 595
that includes, but is not limited to, pricing assumptions and claims 596
experience, and premium rates and loss ratios from the inception of the 597
contract. The commissioner [may refuse such approval if the 598
commissioner finds such rates to] shall adopt regulations, in accordance 599 Substitute Bill No. 10
LCO 20 of 26
with the provisions of chapter 54, to prescribe standards to ensure that 600
such amounts shall not be excessive, inadequate, [or] discriminatory or 601
unaffordable pursuant to the provisions of section 15 of this act. As used 602
in this subsection, "loss ratio" means the ratio of incurred claims to 603
earned premiums by the number of years of policy duration for all 604
combined durations. 605
Sec. 14. Subsection (a) of section 38a-218 of the general statutes is 606
repealed and the following is substituted in lieu thereof (Effective January 607
1, 2026): 608
(a) No such medical service corporation shall enter into any contract 609
with subscribers unless and until it has filed with the Insurance 610
Commissioner a full schedule of the rates to be paid by the subscriber 611
and has obtained said commissioner's approval [thereof] in accordance 612
with the provisions of section 15 of this act. Such filing shall include an 613
actuarial memorandum that includes, but is not limited to, pricing 614
assumptions and claims experience, and premium rates and loss ratios 615
from the inception of the contract. The commissioner [may refuse such 616
approval if the commissioner finds such rates are] shall adopt 617
regulations, in accordance with the provisions of chapter 54, to prescribe 618
standards to ensure that such amounts shall not be excessive, 619
inadequate, [or] discriminatory or unaffordable pursuant to the 620
provisions of section 15 of this act. As used in this subsection, "loss ratio" 621
means the ratio of incurred claims to earned premiums by the number 622
of years of policy duration for all combined durations. 623
Sec. 15. (NEW) (Effective January 1, 2026) (a) (1) With respect to a 624
health insurance policy, agreement or contract that provides coverage 625
of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 626
38a-469 of the general statutes, any (A) rate filed for such policy 627
pursuant to section 38a-481 of the general statutes, as amended by this 628
act, (B) rate filed for such policy pursuant to section 38a-513 of the 629
general statutes, as amended by this act, (C) schedule of amounts filed 630
for such agreement pursuant to section 38a-183 of the general statutes, 631
as amended by this act, (D) schedule of rates filed for such contract 632 Substitute Bill No. 10
LCO 21 of 26
pursuant to section 38a-208 of the general statutes, as amended by this 633
act, or (E) schedule of rates filed for such contract pursuant to section 634
38a-218 of the general statutes, as amended by this act, on or after 635
January 1, 2026, shall be filed not later than one hundred twenty 636
calendar days prior to the proposed effective date of such rates or 637
amounts. 638
(2) Each filer making a rate or amount filing pursuant to this 639
subsection shall, on the date such filer submits such rate or amount 640
filing to the Insurance Commissioner, include with such filer's rate or 641
amount filing an actuarial memorandum, certified by a qualified 642
actuary, that to the best of such actuary's knowledge, (A) such rate or 643
amount filing is in compliance with the laws of this state and federal 644
law, as applicable, and (B) the rate or amount filing is not excessive, as 645
described in subdivision (1) of subsection (c) of this section. For the 646
purposes of this subparagraph, "qualified actuary" means a member in 647
good standing of the American Academy of Actuaries who is qualified 648
in accordance with the standards of the American Academy of 649
Actuaries. 650
(3) (A) Notwithstanding the provisions of section 38a-69a of the 651
general statutes, the Insurance Department shall post on the 652
department's Internet web site all documents, materials and other 653
information provided to or requested by the department in relation to 654
any such rate or amount filing made pursuant to this subsection, 655
including, but not limited to, financial reports, financial statements, 656
actuarial reports and actuarial memoranda. Such rate or amount filing 657
and such documents, materials and other information shall be posted 658
on such web site not later than three business days after the department 659
receives such filing, and such posting shall be updated to include any 660
correspondence between the department and such filer. 661
(B) The department shall provide for a written public comment 662
period of not less than thirty calendar days following the posting of such 663
filing. The department shall include in such posting the date such public 664
comment period closes and instructions for the public to submit 665 Substitute Bill No. 10
LCO 22 of 26
comments to the department. 666
(b) (1) The commissioner shall hold a public hearing for each rate or 667
amount filed under the provisions of subdivision (1) of subsection (a) of 668
this section. Not later than five business days after the posting of such 669
rate or amount filing on the department's Internet web site in 670
accordance with the provisions of subparagraph (A) of subdivision (3) 671
of subsection (a) of this section, the commissioner shall set a public 672
hearing date for such rate or amount filing and shall post the date, place 673
and time of such public hearing in a conspicuous place on the 674
department's Internet web site. 675
(2) Such public hearing shall be (A) held after the end of the public 676
comment period specified in subparagraph (B) of subdivision (3) of 677
subsection (a) of this section, but not later than prior to the proposed 678
effective date of such rate or amount, at a place and time that is 679
convenient to the public, and (B) conducted in accordance with the 680
provisions of chapter 54 of the general statutes, this section and section 681
16 of this act. 682
(3) Upon setting the date, place and time of the public hearing for 683
such rate or amount filing, the commissioner shall immediately notify 684
the filer of such rate or amount filing of the date, place and time of the 685
public hearing. 686
(c) The commissioner shall not approve a rate or amount filing 687
submitted in accordance with the provisions of this section if such rate 688
or amount filing is excessive, inadequate, unfairly discriminatory or 689
unaffordable. The commissioner shall conduct an actuarial review to 690
determine if the methodology and assumptions used to develop such 691
rate or amount filing are actuarially sound and in compliance with the 692
Actuarial Standards of Practice issued by the Actuarial Standards Board. 693
(1) Any rate or amount shall be considered excessive if it is 694
unreasonably high for the insurance provided in relation to the 695
underlying risks and costs after due consideration of: (A) The 696
experience of such filer; (B) such filer's past and projected costs, 697 Substitute Bill No. 10
LCO 23 of 26
including amounts to be paid for commissions; (C) any transfers of 698
funds to the holding or parent company, subsidiary or affiliate of such 699
filer; (D) such filer's rate of return on assets or profitability, as compared 700
to similar filers; (E) a reasonable margin for profit and contingencies; (F) 701
any public comments received on such filing in accordance with the 702
provisions of subparagraph (B) of subdivision (3) of subsection (a) of 703
this section; and (G) other factors the commissioner deems relevant. 704
(2) Any rate or amount shall be considered inadequate if such rate or 705
amount is unreasonably low for the insurance provided in relation to 706
the underlying risks and costs and continued use of such rate or amount 707
would endanger solvency of such filer. 708
(3) Any rate or amount shall be considered unfairly discriminatory if 709
the premium charged for any classification is not reasonably related to 710
the underlying risks and costs, such that different premiums result for 711
insureds with similar risks and costs. 712
(4) Any rate or amount shall be considered unaffordable if the 713
commissioner determines such rate or amount is inconsistent with the 714
inflation-adjusted Connecticut Health Affordability Index 715
commissioned by the Office of Health Strategy and the Office of the 716
State Comptroller, or another metric jointly designated by the 717
commissioner and the Commissioner of Health Strategy. 718
(d) Not later than thirty days after such public hearing held in 719
accordance with the provisions of subsection (b) of this section, the 720
commissioner shall issue a written decision approving, disapproving or 721
modifying such rate or amount filing. Such decision shall specify all 722
factors used to reach such decision and shall be posted on the 723
department's Internet web site not later than two business days after the 724
commissioner issues such decision. 725
Sec. 16. (NEW) (Effective January 1, 2026) (a) Notwithstanding sections 726
4-176 and 4-177a of the general statutes, the Healthcare Advocate or the 727
Attorney General, or both, may be parties to any public hearing held in 728
accordance with the provisions of section 15 of this act. 729 Substitute Bill No. 10
LCO 24 of 26
(b) Subject to the provisions of section 4-181 of the general statutes, 730
(1) the Healthcare Advocate or the Attorney General, or both, shall have 731
access to the records of the Insurance Department regarding any rate or 732
amount filing made in accordance with the provisions of section 15 of 733
this act, and (2) attorneys, actuaries, accountants and other experts who 734
are part of the Insurance Commissioner's staff and who review or assist 735
in the determination of such filing pursuant to the provisions of section 736
15 of this act shall cooperate with the Healthcare Advocate or Attorney 737
General, or both, to carry out the provisions of this section. 738
(c) The Healthcare Advocate or the Attorney General, or both, may 739
(1) summon and examine under oath such witnesses as the Healthcare 740
Advocate or the Attorney General deems necessary for the review of a 741
rate or amount filing made in accordance with the provisions of section 742
15 of this act, and (2) require the filer or any holding or parent company 743
or subsidiary of such filer to produce books, vouchers, memoranda, 744
papers, letters, contracts and other documents, regardless of the format 745
in which such materials are stored. Any such books, vouchers, 746
memoranda, papers, letters, contracts or other documents shall be 747
limited to such information or transactions between such filer and the 748
holding or parent company or subsidiary that are reasonably related to 749
the subject matter of the filing. 750
Sec. 17. (NEW) (Effective January 1, 2026) (a) As used in this section: 751
(1) "General anesthesia" has the same meaning as provided in section 752
20-123a of the general statutes; and 753
(2) "Medical necessity" has the same meaning as provided in section 754
38a-482a of the general statutes. 755
(b) No individual health insurance policy providing coverage of the 756
type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 757
of the general statutes delivered, issued for delivery, renewed, amended 758
or continued in this state on or after January 1, 2026, shall (1) if such 759
policy provides coverage for general anesthesia, (A) impose an arbitrary 760
time limit on reimbursement for general anesthesia provided during 761 Substitute Bill No. 10
LCO 25 of 26
any medically necessary procedure, or (B) deny, reduce, terminate or 762
fail to provide such reimbursement, in whole or in part, for general 763
anesthesia solely because the duration of care exceeded a predetermined 764
time limit as determined by the insurer, or (2) impose unilateral 765
arbitrary limitations on reimbursement for medically necessary 766
ancillary services. 767
(c) The medical necessity for administering general anesthesia during 768
any medical procedure shall be determined by the attending board-769
certified anesthesiologist during such medical procedure. 770
Sec. 18. (NEW) (Effective January 1, 2026) (a) As used in this section: 771
(1) "General anesthesia" has the same meaning as provided in section 772
20-123a of the general statutes; and 773
(2) "Medical necessity" has the same meaning as provided in section 774
38a-482a of the general statutes. 775
(b) No group health insurance policy providing coverage of the type 776
specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 of 777
the general statutes delivered, issued for delivery, renewed, amended 778
or continued in this state on or after January 1, 2026, shall (1) if such 779
policy provides coverage for general anesthesia, (A) impose an arbitrary 780
time limit on reimbursement for general anesthesia provided during 781
any medically necessary procedure, or (B) deny, reduce, terminate or 782
fail to provide such reimbursement, in whole or in part, for general 783
anesthesia solely because the duration of care exceeded a predetermined 784
time limit as determined by the insurer, or (2) impose unilateral 785
arbitrary limitations on reimbursement for medically necessary 786
ancillary services. 787
(c) The medical necessity for administering general anesthesia during 788
any medical procedure shall be determined by the attending board-789
certified anesthesiologist during such medical procedure. 790 Substitute Bill No. 10
LCO 26 of 26
This act shall take effect as follows and shall amend the following
sections:
Section 1 October 1, 2025 New section
Sec. 2 October 1, 2025 38a-477ee(c)
Sec. 3 from passage New section
Sec. 4 October 1, 2025 New section
Sec. 5 January 1, 2026 38a-591c(a) and (b)
Sec. 6 January 1, 2026 38a-591e(c)
Sec. 7 January 1, 2026 38a-510
Sec. 8 January 1, 2026 38a-544
Sec. 9 July 1, 2026 New section
Sec. 10 January 1, 2026 38a-481(a) to (c)
Sec. 11 January 1, 2026 38a-513
Sec. 12 January 1, 2026 38a-183(a)(1)
Sec. 13 January 1, 2026 38a-208(a)
Sec. 14 January 1, 2026 38a-218(a)
Sec. 15 January 1, 2026 New section
Sec. 16 January 1, 2026 New section
Sec. 17 January 1, 2026 New section
Sec. 18 January 1, 2026 New section
Statement of Legislative Commissioners:
In Section 6(c)(1)(C)(i), "subdivision (1)" was changed to "subdivision
(2)" for accuracy, in Section 15(c)(4), "executive director of the Office of
Health Strategy" was changed to "Commissioner of Health Strategy"
for accuracy, and in Section 16(b)(2), "the provisions of" was added
after "pursuant to" for consistency.
INS Joint Favorable Subst.