SB 977 — AN ACT CONCERNING EXPLANATIONS OF BENEFITS.

General Assembly RaisedSubstitute Bill No.

977 January Session, 2019 LCOAN No.ACT CONCERNING EXPLANATIONS OF BENEFITS.

4872 Referred to Committee on INSURANCE AND REAL ESTATE Introduced by:

(INS) AN ACT CONCERNING EXPLANATIONS OF BENEFITS.

LCO[(B) No.any] (ii) Any restrictions on the use or quantity of a covered benefit, including on prescription drugs or drugs administered in a physician's office or a clinic;

4872[(C) 1a] of(iii) 6A Raisedspecific Billdescription No.977of [(B)how any]prescription (ii)drugs Anyare restrictionsincluded on the use or quantityexcluded offrom aany coveredapplicable benefit,deductible, including ona prescriptionLCO drugs\\PRDFS1\SCOUSERS\FORZANOF\WS\2019SB-00977-R01 orof drugs7 administeredSB.docx inSubstitute aBill physician'sNo. office or a clinic;

[(C)977 a] (iii) A specific description of how prescription drugs are included or excluded from any applicable deductible, including a description of other out-of-pocket expenses that apply to such drugs;

or (iii) Use a method specified by such consumer to issue such explanations of benefits to such consumer, and provide sufficient space in the statement for such consumer to specify a mailing address, electronic mail address or telephone number for such insurer, center, corporation, society or entity, or a third-party administratoradministrator, as defined in section 38a-720, to use to contact such consumer regarding confidential information concerning covered benefits provided to such consumer.

LCO(A) No.[whether] Whether a specific prescription drug is available under such policy's drug formulary;

4872(B) 2[the] ofThe 6coinsurance, Raisedcopayment, Billdeductible No.977or (A)other [whether]out-of- WhetherLCO a{\\PRDFS1\SCOUSERS\FORZANOF\WS\2019SB-00972 specificof prescription7 drugR01-SB.docx is} availableSubstitute underBill suchNo. policy's drug formulary;

(B)977 [the] The coinsurance, copayment, deductible or other out-of- pocket expense applicable to such drug;

(d) (1) Except as provided in subdivision (2) of this subsection, each insurer, health care center, hospital service corporation, medical service corporation, fraternal benefit society or other entity that delivers, issues for delivery, renews, amends or continues a health LCOinsurance No.policy described in subsection (a) of this section shall:

4872(A) 3Issue ofan 6explanation Raisedof Billbenefits No.977to insuranceeach policyconsumer describedwho inis subsectiona (a)LCO {\\PRDFS1\SCOUSERS\FORZANOF\WS\2019SB-009773 of this7 sectionR01-SB.docx shall:} Substitute Bill No.

(A)977 Issue explanations of benefits to the consumers who are covered individualsindividual under the policy;

and (B) (i) Permit each consumer who is a covered individual under the policy and legally capable of consenting to the provision of covered benefits to specify the method that such insurer, center, corporation, society or entity shall use to issue toan suchexplanation consumer explanations of benefits concerning benefits provided to such consumer, which method may include, but need not be limited to:

(I) Mailing such explanationsexplanation of benefits to the policyholder's mailing address, such consumer's mailing address or another mailing address specified by such consumer;

(II) Sending such explanationsexplanation of benefits by electronic means, including, but not limited to, electronic mail;

or (III) Making such explanationsexplanation of benefits available solely to such consumer by electronic means, provided making such explanationsexplanation of benefits available solely to such consumer by electronic means complies with all applicable federal and state laws and regulations concerning data security, including, but not limited to, 45 CFR Part 160160, as amended from time to time, and 45 CFR Part 164, Subparts A and C, as the same may be amended from time to time.

Such insurer, center, corporation, society or entity shall comply with a specification under clausesthis (i)clause orand (ii)clause (i) of this subparagraph not later than three calendar days after the date of such specification, if such specification was made by electronic or telephonic means, or seven days after the date such insurer, center, corporation, society or entity received such specification by first-class mail, providedexcept that such insurer, center, corporation, society or entity may adhere to an electronic or telephonic specification and request that a consumer send to such insurer, center, LCO {\\PRDFS1\SCOUSERS\FORZANOF\WS\2019SB-00977-4 of 7 R01-SB.docx } Substitute Bill No.

4872977 4 of 6 Raised Bill No.977 adhere to an electronic or telephonic specification and request that a consumer send to such insurer, center, corporation, society or entity written confirmation of such specification by first-class mail.

(2) Each consumer who is a covered individual under a policy described in subsection (a) of this section, is legally capable of consenting to the provision of covered benefits and is not financially liable for such benefits may specify, either orally or in writing, that the insurer, center, corporation, society or entity that delivered, issued for delivery, renewed, amended or continued the policy not issue explanationsan explanation of benefits concerning such consumer pursuant to subdivision (1) of this subsection.

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4872 5 of 6 Raised Bill No.

(5) No insurer, center, corporation, society or entity that is subject to this subsection shall require a consumer or a policyholder to waive any right to limit disclosure under this subsection as a precondition to delivering, issuing for delivery, renewing, amending or continuing a policy described in subsection (a) of this section to the consumer or policyholder.

Section 1 January 1, 2020 Section 1 38a-477d Statement of Purpose:Legislative Commissioners:

ToIn requireSubsec. health carriers that deliver, issue for delivery, renew, amend or continue certain health insurance policies in this state to issue explanations of benefits to consumers in certain circumstances, disclose information concerning explanations of benefits to consumers, and require that explanations of benefits be maintained as confidential in certain circumstances.

except(d)(1)(A), that"an" whenwas theinserted entirebefore text"explanations", of"explanation" awas billsubstituted orfor resolution"explanations", or"each" awas sectionsubstituted offor a"the", bill"consumer" orwas resolutionsubstituted isfor new,"consumers", it"is isa" notwas underlined.]substituted LCOfor No."are" and "individual" was substituted for "individuals" for consistency;

4872in 6Subsec. of 6

(d)(1)(B)(i), "an explanation" was substituted for "to such consumer explanations" for consistency and conciseness;

in Subsecs.

(d)(1)(B)(i)(I) and (II), "explanation" was substituted for "explanations" for consistency;

in Subsec.

(d)(1)(B)(i)(III), "explanation" was substituted for "explanations", ", as amended from time to time," was inserted after "45 CFR Part 160" and "the same may be" was deleted for consistency;

in Subsec.

(d)(1)(B)(ii), "this clause and clause (i)" was substituted for "clauses (i) or (ii)" and "except that" was substituted for "provided" for consistency;

in Subsec.

(d)(2), "is" was inserted before "legally" and "not financially" for clarity, and "an explanation" was substituted for "explanations" for consistency;

and in Subsec.

(d)(5), "policyholder" was substituted for "a policyholder" for conciseness.

LCO {\\PRDFS1\SCOUSERS\FORZANOF\WS\2019SB-00977- 6 of 7 R01-SB.docx } Substitute Bill No.