Connecticut 2021 Regular Session Status: Passed Senate 2 D cosponsors

SB 1045 — AN ACT CONCERNING STEP THERAPY, ADVERSE DETERMINATION AND UTILIZATION REVIEWS, AND HEALTH INSURANCE COVERAGE FOR CHILDREN, STEPCHILDREN AND OTHER DEPENDENT CHILDREN.

Last action — HOUSE CALENDAR NUMBER 512

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  1. ✓
    Introduced
  2. ✓
    In Committee
  3. 3
    Passed Senate
  4. 4
    Passed House
  5. 5
    To Executive
  6. 6
    Enacted

This bill died with 2021 Regular Session. It reached “Passed Senate” and never advanced before the session ended, so it can no longer move — a new version would have to be reintroduced in the current session.

This bill is no longer active — its legislative session has ended, so there is no live prognosis. It would have to be reintroduced in the current session to move again.

Bill Text

What changed in the latest version

47 added · 184 removed

47 line(s) added, 184 removed.

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Senate General Assembly File No.
General Assembly Raised Bill No.
370 January Session, 2021 Senate Bill No.
1045 January Session, 2021 LCO No.
1045 Senate, April 8, 2021 The Committee on Insurance and Real Estate reported through SEN.
3686 ReferredtoCommitteeonINSURANCE ANDREAL ESTATE Introduced by:
LESSER of the 9th Dist., Chairperson of the Committee on the part of the Senate, that the bill ought to pass.
(INS) AN ACT CONCERNING STEP THERAPY, ADVERSE DETERMINATION AND UTILIZATION REVIEWS, AND HEALTH INSURANCE COVERAGE FOR CHILDREN, STEPCHILDREN AND OTHER DEPENDENT CHILDREN.
AN ACT CONCERNING STEP THERAPY, ADVERSE DETERMINATION AND UTILIZATION REVIEWS, AND HEALTH INSURANCE COVERAGE FOR CHILDREN, STEPCHILDREN AND OTHER DEPENDENT CHILDREN.
Each such policy shall cover a stepchild or other dependent child on the same basis as a SB1045 / File No.
Each such policy shall cover a stepchild or other dependent child on the same basis as a biological child.
370 1 SB1045 File No.
LCO 3686 \\PRDFS1\SCOUSERS\FORZANOF\WS\2021SB-01045-R1 of 11 SB.docx Raised Bill No.
370 biological child.
1045 Sec.
Sec.
Subsection (a) of section 38a-510 of the general statutes is repealedandthefollowingissubstitutedinlieuthereof(EffectiveJanuary 1, 2022):
Subsection (a) of section 38a-510 of the general statutes is repealedandthefollowingissubstituted inlieuthereof(EffectiveJanuary 1, 2022):
[,] or (B) [a] A prescribed drug for [cancer] treatment of a behavioral health SB1045 / File No.
[,] or (B) [a] A prescribed drug for [cancer] treatment of a behavioral health condition or a chronic, disabling or life-threatening condition or disease LCO 3686 {\\PRDFS1\SCOUSERS\FORZANOF\WS\2021SB-010452 of 11 R02-SB.docx } Raised Bill No.
370 2 SB1045 File No.
1045 for aninsuredwho has beendiagnosedwith [stage IV metastaticcancer] such a condition or disease, provided such prescribed drug is in compliance with approved federal Food and Drug Administration indications.
370 condition or a chronic, disabling or life-threatening condition or disease for aninsuredwho has beendiagnosedwith [stage IV metastaticcancer] such a condition or disease, provided such prescribed drug is in compliance with approved federal Food and Drug Administration indications.
or (2) Require, if such insurance company, hospital service corporation, SB1045 / File No.
or (2) Require, if such insurance company, hospital service corporation, LCO 3686 {\\PRDFS1\SCOUSERS\FORZANOF\WS\2021SB-0103 of 11 R02-SB.docx } Raised Bill No.
370 3 SB1045 File No.
1045 medical service corporation, health care center or other entity uses step therapy for such drugs, the use of step therapy for:
370 medical service corporation, health care center or other entity uses step therapy for such drugs, the use of step therapy for:
SB1045 / File No.
LCO 3686 {\\PRDFS1\SCOUSERS\FORZANOF\WS\2021SB-0104 of 11 R02-SB.docx } Raised Bill No.
370 4 SB1045 File No.
1045 (i) Holds a nonrestricted license in a state of the United States [and] in the same [or similar] specialty as [typically manages the medical condition,procedureor treatment]thetreating physicianorotherhealth care professional under review;
370 (i) Holds a nonrestricted license in a state of the United States [and] in the same [or similar] specialty as [typically manages the medical condition, procedureor treatment]thetreating physicianorotherhealth care professional under review;
(2)(A)Eachutilizationreviewprogramshalluse documented clinical SB1045 / File No.
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370 5 SB1045 File No.
1045 (2)(A)Eachutilizationreviewprogramshalluse documentedclinical review criteria that are based on sound clinical evidence and are evaluated periodically by the health carrier's organizational mechanism specified in subparagraph (F) of subdivision (2) of subsection (c) of section 38a-591b to assure such program's ongoing effectiveness.
370 review criteria that are based on sound clinical evidence and are evaluated periodically by the health carrier's organizational mechanism specified in subparagraph (F) of subdivision (2) of subsection (c) of section 38a-591b to assure such program's ongoing effectiveness.
(A) The most recent edition of the American Society of Addiction Medicine Treatment Criteria for Addictive, Substance- Related,andCo-OccurringConditions;or(B)clinicalreviewcriteriathat the health carrier demonstrates to the Insurance Department is consistent with the most recent edition of the American Society of Addiction Medicine Treatment Criteria for Addictive, Substance- SB1045 / File No.
(A) The most recent edition of the American Society of Addiction Medicine Treatment Criteria for Addictive, Substance- Related,andCo-OccurringConditions;or(B)clinicalreviewcriteriathat the health carrier demonstrates to the Insurance Department is LCO 3686 {\\PRDFS1\SCOUSERS\FORZANOF\WS\2021SB-0106 of 11 R02-SB.docx } Raised Bill No.
370 6 SB1045 File No.
1045 consistent with the most recent edition of the American Society of Addiction Medicine Treatment Criteria for Addictive, Substance- Related, and Co-Occurring Conditions, except that nothing in this subdivision shall prohibit a health carrier from developing its own clinical review criteria or purchasing or licensing additional clinical review criteria from qualified vendors approved by the commissioner, to address advancements in technology or types of care for the treatment of a substance use disorder, that are not covered in the most recent editionoftheAmericanSociety ofAddiction Medicine Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions.
370 Related, and Co-Occurring Conditions, except that nothing in this subdivision shall prohibit a health carrier from developing its own clinical review criteria or purchasing or licensing additional clinical review criteria from qualified vendors approved by the commissioner, to address advancements in technology or types of care for the treatment of a substance use disorder, that are not covered in the most recent editionoftheAmericanSociety ofAddiction Medicine Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions.
(5) For any utilization review for the treatment of an adult mental disorder, the clinical review criteria used shall be:
LCO 3686 {\\PRDFS1\SCOUSERS\FORZANOF\WS\2021SB-0107 of 11 R02-SB.docx } Raised Bill No.
(A) The most recent guidelines of the American Psychiatric Association or the most recent SB1045 / File No.
1045 (5) For any utilization review for the treatment of an adult mental disorder, the clinical review criteria used shall be:
370 7 SB1045 File No.
(A) The most recent guidelines of the American Psychiatric Association or the most recent Standardsand Guidelinesofthe Associationfor Ambulatory Behavioral Healthcare;
370 Standardsand Guidelinesofthe Associationfor Ambulatory Behavioral Healthcare;
(2) In determining whether a benefit request shall be considered an urgent care request, an individual acting on behalf of a health carrier shall apply the judgment of a prudent layperson who possesses an average knowledge of health and medicine, except that any benefit request (A) determined to be an urgent care request by a health care SB1045 / File No.
(2) In determining whether a benefit request shall be considered an urgent care request, an individual acting on behalf of a health carrier LCO 3686 {\\PRDFS1\SCOUSERS\FORZANOF\WS\2021SB-010458 of 11 R02-SB.docx } Raised Bill No.
370 8 SB1045 File No.
1045 shall apply the judgment of a prudent layperson who possesses an average knowledge of health and medicine, except that any benefit request (A) determined to be an urgent care request by a health care professional with knowledge of the covered person's medical condition, or (B) specified under subparagraph (B) or (C) of subdivision (38) of section 38a-591a, as amended by this act, shall be deemed an urgent care request.
370 professional with knowledge of the covered person's medical condition, or (B) specified under subparagraph (B) or (C) of subdivision (38) of section 38a-591a, as amended by this act, shall be deemed an urgent care request.
(3)(A)Atthetimeahealthcarriernotifiesacoveredperson,acovered person's authorized representative or a covered person's health care professionalofaninitialadverse determinationthatwasbased,inwhole or in part, on medical necessity, of a concurrent or prospective utilization review or of a benefit request, the health carrier shall notify the covered person's health care professional (i) of the opportunity for a conference as provided in subparagraph (B) of this subdivision, and (ii) that such conference shall not be considered a grievance of such initial adverse determination as long as a grievance has not been filed as set forth in subparagraph (B) of this subdivision.
(3)(A)Atthetimeahealthcarriernotifiesacoveredperson,acovered person's authorized representative or a covered person's health care professionalofaninitialadversedeterminationthatwasbased,inwhole or in part, on medical necessity, of a concurrent or prospective utilization review or of a benefit request, the health carrier shall notify the covered person's health care professional (i) of the opportunity for a conference as provided in subparagraph (B) of this subdivision, and (ii) that such conference shall not be considered a grievance of such initial adverse determination as long as a grievance has not been filed as set forth in subparagraph (B) of this subdivision.
(c) (1) (A) When conducting a review of an adverse determination under this section, the health carrier shall ensure that such review is conducted in a manner to ensure the independence and impartiality of SB1045 / File No.
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370 9 SB1045 File No.
1045 (c) (1) (A) When conducting a review of an adverse determination under this section, the health carrier shall ensure that such review is conducted in a manner to ensure the independence and impartiality of the clinical peer or peers involved in making the review decision.
370 the clinical peer or peers involved in making the review decision.
Such documents, communications, information, evidence and rationale shall be provided sufficiently in advance of the date the health carrier is required to issue a decision to permit the covered person or the covered person's authorized representative, as applicable, a reasonable opportunity to respond prior to such date.
Such documents, communications, information, evidence and rationale shall be provided sufficiently in advance of the date the health carrier is required to issue a decision to LCO 3686 {\\PRDFS1\SCOUSERS\FORZANOF\WS\2021SB-0110 of 11 R02-SB.docx } Raised Bill No.
SB1045 / File No.
1045 permit the covered person or the covered person's authorized representative, as applicable, a reasonable opportunity to respond prior to such date.
370 10 SB1045 File No.
(2) If the review under subdivision (1) of this subsection is an expedited review, all necessary information, including the health carrier'sdecision,shall betransmittedbetweenthehealthcarrierandthe covered person or the covered person's authorized representative, as applicable, by telephone, facsimile, electronic means or any other expeditious method available.
370 (2) If the review under subdivision (1) of this subsection is an expedited review, all necessary information, including the health carrier'sdecision,shall betransmittedbetweenthehealthcarrierandthe covered person or the covered person's authorized representative, as applicable, by telephone, facsimile, electronic means or any other expeditious method available.
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8 January 1, 2022 38a-591e(c) INS Joint Favorable SB1045 / File No.
8 January 1, 2022 38a-591e(c) INS Joint Favorable APP Joint Favorable LCO 3686 {\\PRDFS1\SCOUSERS\FORZANOF\WS\2021SB-01045-11 of 11 R02-SB.docx }
370 11 SB1045 File No.
370 The following Fiscal Impact Statement and Bill Analysis are prepared for the benefit of the members of the General Assembly, solely for purposes of information, summarization and explanation and do not represent the intent of the General Assembly or either chamber thereof for any purpose.
In general, fiscal impacts are based upon a variety of informational sources, including the analyst’s professional knowledge.
Whenever applicable, agency data is consulted as part of the analysis, however final products do not necessarily reflect an assessment from any specific department.
OFA Fiscal Note State Impact:
Agency Affected Fund-Effect FY 22 $ FY 23 $ State – ACA Mandate GF - Cost See Below See Below Note:
GF=General Fund Municipal Impact:
Municipalities Effect FY 22 $ FY 23 $ Various Municipalities STATE See Below See Below MANDATE 1 - Cost Explanation The bill does not result in a fiscal impact to the state employee and retiree health plan or municipalities that participate in the Partnership Plan as step therapy is not required by the plans.
The bill will increase costs to certain fully insured municipal plans which currently require step therapy for conditions specified in the bill.
The coverage requirements will result in increased premium costs when municipalities enter into new health insurance contracts after January 1, 2022.
In addition, many municipal health plans are recognized as “grandfathered” health plans under the Affordable Care Act (ACA).
It is unclear what effect the adoption of certain health mandates will have on the grandfathered status of certain municipal plans under ACA.
1State mandate is defined in Sec.
2-32b(2) of the Connecticut General Statutes, "state mandate" means any state initiated constitutional, statutory or executive action that requires a local government to establish, expand or modify its activities in such a way as to necessitate additional expenditures from local revenues.
SB1045 / File No.
370 12 SB1045 File No.
370 Pursuant to federal law, self-insured health plans are exempt from state health insurance mandates.
To the extent that step therapy is required by the drug formulary for plans under the Exchange, there is a cost to the state to defray costs.
The cost to the state will vary based on the impact to plan premiums, based on current and projected utilization of step therapy for the treatments outlined in the bill.
While states are allowed to mandate benefits in excess of the essential health benefit (EHB), federal law requires the state to defray the cost of any such additional mandated benefits for all plans sold in the exchange, by reimbursing the carrier or the insured for the excess coverage.
Absent further federal guidance, state mandated benefits enacted after December 31, 2011 cannot be considered part of the EHB unless they are already part of the benchmark plan.
The Out Years The fiscal impact in the outyears will vary based on an increase in premiums.
SB1045 / File No.
370 13 SB1045 File No.
370 OLR Bill Analysis SB 1045 AN ACT CONCERNING STEP THERAPY, ADVERSE DETERMINATION AND UTILIZATION REVIEWS, AND HEALTH INSURANCE COVERAGE FOR CHILDREN, STEPCHILDREN AND OTHER DEPENDENT CHILDREN.
SUMMARY This bill establishes a rebuttable presumption in a utilization or adverse determination review that a health care service ordered by a healthprofessionalactingwithinhisorherscopeofpracticeismedically necessary.
For utilization reviews, the bill imposes on carriers or utilizationreviewcompaniestheburdenofproving ahealthcare service is not medically necessary.
For adverse determination reviews, a carrier may rebut the assumption by reasonably substantiating to the clinical peers conducting the review that the service is not medically necessary.
(Utilizationandadverse determinationreviewsare stepsindetermining whether a specific service is covered and reimbursed, see BACKGROUND.) The bill also expands current law’s prohibition on step therapy to include prescription drugs prescribed to treat a behavioral health condition or a disabling, chronic, or life-threatening condition or disease.
The bill increases the education requirements to qualify as a clinical peer for utilization and adverse determination reviews unrelated to the urgent treatment of substance use or mental disorders, generally aligning themwiththerequirementsfor clinicalpeersthat do treat those reviews.
It also requires health carriers to authorize clinical peers to reverse initial adverse determinations.
Current law requires certain health insurance policies to cover SB1045 / File No.
370 14 SB1045 File No.
370 children until age 26, or earlier if they receive coverage through their employer.
The bill instead requires policies to cover them until age 26 regardless of whether they have coverage through their employer, and it extends this requirement to stepchildren and other dependent children.
EFFECTIVE DATE:
January 1, 2022 §§ 3 & 4 — STEP THERAPY Step therapy is a protocol establishing the sequence for prescribing drugs for specific medical conditions that generally requires patients to try less expensive drugs before higher cost drugs.
The bill prohibits health insurers from requiring an insured to use step therapy for prescribed drugs to treat a behavioral health condition or a disabling, chronic, or life-threatening condition or disease, provided the drug is prescribed in accordance with federal Food and Drug Administration indications.
Current law limits this prohibition to drugs used to treat stage IV metastatic cancer.
By law, step therapy cannot be used for longer than 60 days.
§§ 1 & 2 — DEPENDENT CHILDREN COVERAGE The bill requires certain health insurance policies to cover stepchildren and other dependent children until the policy anniversary date after they turn 26 years old.
The provisions apply to fully insured individual and group coverage health insurance policies delivered, issued, renewed, amended, or continued in Connecticut that cover (1) basic hospital expenses;
(2) basic medical-surgical expenses;
(3) major medical expenses;
or (4) hospital or medical services, including those provided under an HMO plan.
It also applies to individual health insurance policies that cover (1) limited benefits and (2) accidents only.
The bill also eliminates a provision allowing these health plans to terminate coverage for children before they reach age 26 if they become covered through their own employment.
(Because of the federal Employee Retirement Income Security Act (ERISA), state insurance benefit mandates do not apply to self-insured SB1045 / File No.
370 15 SB1045 File No.
370 benefit plans.) § 5 — REQUIREMENTS FOR CLINICAL PEERS Under current law, clinical peers conducting utilization or adverse determination reviews unrelated to the urgent treatment of substance use or mental disorders must have a nonrestricted license in the same or similar specialty that typically manages the medical condition, procedures, or treatment under review.
The bill instead requires these clinical peers to have a nonrestricted license in the same specialty.
Additionally, these clinical peers must have:
1.
a doctoral or medical degree;
and 2.
either an appropriate national board certification, including at the subspecialty level if possible, or actively practice and typically manage the condition or procedure under review.
BACKGROUND Utilization and Adverse Determination Reviews Generally, reviews have up to three steps:
(1) an initial utilization review to determine if the procedure is covered;
(2) a grievance review (i.e., internal review), which occurs when a covered person appeals a benefit denial (i.e., adverse determination);
and (3) an external review, which is conducted when a covered person exhausts a health carrier’s internal process and appeals the carrier’s adverse determination to the insurance department.
External reviews, also called final adverse determination reviews, are conducted by an independent review organization assigned by the insurance department.
COMMITTEE ACTION Insurance and Real Estate Committee Joint Favorable Yea 15 Nay 3 (03/22/2021) SB1045 / File No.
370 16
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Action History

  1. HOUSE CALENDAR NUMBER 512

  2. FAV. RPT., TABLED FOR HOUSE CALENDAR

  3. SENATE PASSED

  4. FAV. RPT., TAB. FOR CAL., SEN.

  5. NO NEW FILE BY COMM. ON Appropriations

  6. RPTD. OUT OF LCO

  7. FILED WITH LCO

  8. Joint Favorable

  9. REF. BY SEN. TO COMM. ON Appropriations

  10. FILE NO. 370

  11. SENATE CALENDAR NUMBER 237

  12. FAV. RPT., TAB. FOR CAL., SEN.

  13. RPTD. OUT OF LCO

  14. REFERRED TO Office of Legislative Research AND Office of Fiscal Analysis 04/07/21

  15. FILED WITH LCO

  16. Joint Favorable

  17. PUBLIC HEARING 0318

  18. REF. TO JOINT COMM. ON Insurance and Real Estate

Sponsors

Sponsorship breakdown

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2 sponsors · 0 co-sponsors · 185 not signed on

Sponsors (2)

Co-sponsors (0)

None.

Not signed on (185)

185 members have not signed on to this bill.

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"Not signed on" means a member has not sponsored or co-sponsored this bill — it does not imply opposition. Members flagged Voted No have a recorded No vote on this bill.

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healthcare health-insurance
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Frequently asked questions

Who sponsors SB 1045?
SB 1045 is sponsored by Saud Anwar (Democratic) and Martin M. Looney (Democratic).
What is the current status of SB 1045?
This bill died with 2021 Regular Session. It reached “Passed Senate” and never advanced before the session ended, so it can no longer move — a new version would have to be reintroduced in the current session.
Where can I track SB 1045?
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