SB 6 — AN ACT CONCERNING UTILIZATION REVIEW AND HEALTH CARE CONTRACTS, HEALTH INSURANCE COVERAGE FOR NEWBORNS AND STEP THERAPY.

337 carrier or purchased or licensed from a qualified vendor shall conform to the requirements of subparagraph (A) of subdivision (2) of this subsection.

(c) If a health carrier delegates any utilization review activities to a utilizationLCO review4966 company,{\\PRDFS1\SCOUSERS\FORZANOF\WS\2023SB-00011 the health carrier shall maintain adequate oversight, which shall include (1) a written description of the25 utilizationR03-SB.docx review} company'sCommittee activitiesBill andNo. responsibilities, including such company's reporting requirements, (2) evidence of the health carrier's formal approval of the utilization review company program, and (3) a process by which the health carrier shall evaluate the utilization review company's performance.

SB66 /utilization Filereview No.company, the health carrier shall maintain adequate oversight, which shall include (1) a written description of the utilization review company's activities and responsibilities, including such company's reporting requirements, (2) evidence of the health carrier's formal approval of the utilization review company program, and (3) a process by which the health carrier shall evaluate the utilization review company's performance.

337(d) 11When SB6conducting Fileutilization No.review, the health carrier shall (1) collect only the information necessary, including pertinent clinical information, to make the utilization review or benefit determination, and (2) ensure that such review is conducted in a manner to ensure the independenceandimpartialityoftheindividualorindividualsinvolved in making the utilization review or benefit determination.

337 (d) When conducting utilization review, the health carrier shall (1) collect only the information necessary, including pertinent clinical information, to make the utilization review or benefit determination, and (2) ensure that such review is conducted in a manner to ensure the independenceandimpartialityoftheindividualorindividualsinvolved in making the utilization review or benefit determination.

(a) (1) Each health carrier shall maintain written procedures for (A) utilization review and benefit determinations, (B) expedited utilization review and benefit determinations with respect to prospective urgent care requests and concurrent review urgent care requests, and (C) notifyingLCO covered4966 persons{\\PRDFS1\SCOUSERS\FORZANOF\WS\2023SB-00012 or covered persons' authorized representatives of such25 reviewR03-SB.docx and} benefitCommittee determinations.Bill No.

6 notifying covered persons or covered persons' authorized representatives of such review and benefit determinations.

(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 SB6average /knowledge Fileof No.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 shall be deemed an urgent care request.

337 12 SB6 File No.

337 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 shall be deemed an urgent care request.

Such conference shall not be considered a grievance of suchLCO initial4966 adverse{\\PRDFS1\SCOUSERS\FORZANOF\WS\2023SB-00013 determination.of 25 R03-SB.docx } Committee Bill No.

6 such initial adverse determination.

(1)(A)Foraprospectiveorconcurrentreviewrequest,ahealthcarrier shall make a determination within a reasonable period of time appropriatetothecoveredperson'smedicalcondition,butnotlaterthan [fifteen calendar days] seventy-two hours after the date the health carrier receives such request, and shall notify the covered person and, if SB6applicable, /the Filecovered No.person's authorized representative of such determination, whether or not the carrier certifies the provision of the benefit.

337 13 SB6 File No.

337 applicable, the covered person's authorized representative of such determination, whether or not the carrier certifies the provision of the benefit.

(4) (A) If the extension pursuant to subdivision (3) of this subsection isLCO necessary4966 due{\\PRDFS1\SCOUSERS\FORZANOF\WS\2023SB-0014 to the failure of the25 coveredR03-SB.docx person} orCommittee theBill coveredNo. person's authorized representative to provide information necessary to make a determination on the request, the health carrier shall:

6 is necessary due to the failure of the covered person or the covered person's authorized representative to provide information necessary to make a determination on the request, the health carrier shall:

and (ii) Provide the covered person and, if applicable, the covered person'sauthorizedrepresentative withnot lessthan forty-five calendar days after the date of receipt of the notice to provide the specified SB6information. / File No.

337 14 SB6 File No.

337 information.

(B) Unless the covered person or the covered person's authorized representative hasfailedto provideinformationnecessary for thehealth carrier to make a determination, for an urgent care request specified under subparagraph (B) or (C) of subdivision (38) of section 38a-591a, theLCO health4966 carrier{\\PRDFS1\SCOUSERS\FORZANOF\WS\2023SB-00015 shall make a determination as soon as possible, taking into account the covered person's medical condition, but not later than twenty-four hours after the health carrier receives such request, provided, if the urgent care request is a concurrent review request to extend a course of treatment25 beyondR03-SB.docx the} initialCommittee periodBill ofNo. time or the number of treatments, such request is made [at least] not less than twenty-four hours prior to the expiration of the prescribed period of time or number of treatments.

(2)6 (A)the Ifhealth carrier shall make a determination as soon as possible, taking into account the covered personperson's medical condition, but not later than twenty-four hours after the health carrier receives such request, provided, if the urgent care request is a concurrent review request to extend a course of treatment beyond the initial period of time or the coverednumber person'sof authorizedtreatments, SB6such /request Fileis No.made [at least] not less than twenty-four hours prior to the expiration of the prescribed period of time or number of treatments.

337(2) 15(A) SB6If Filethe No.covered person or the covered person's authorized representative hasfailedto provideinformationnecessary for thehealth carrier to make a determination, the health carrier shall notify the covered person or the covered person's representative, as applicable, as soon as possible, but not later than twenty-four hours after the health carrier receives such request.

337 representative hasfailedto provideinformationnecessary for thehealth carrier to make a determination, the health carrier shall notify the covered person or the covered person's representative, as applicable, as soon as possible, but not later than twenty-four hours after the health carrier receives such request.

(d) (1) [Whenever a health carrier receives a review request from a covered person or a covered person's authorized representative that failsto meet thehealth carrier'sfiling procedures,thehealthcarrier shall notify the covered person and, if applicable, the covered person's authorized representative of such failure not later than five calendar daysLCO after4966 the{\\PRDFS1\SCOUSERS\FORZANOF\WS\2023SB-000016 health carrier receives such request, except that for an urgent care request, the health carrier shall notify the covered person and, if applicable, the covered person's authorized representative of such25 failureR03-SB.docx not} laterCommittee thanBill twenty-fourNo. hours after the health carrier receives such request.] With respect to prospective and concurrent review requests, each health carrier shall:

6 days after the health carrier receives such request, except that for an urgent care request, the health carrier shall notify the covered person and, if applicable, the covered person's authorized representative of such failure not later than twenty-four hours after the health carrier receives such request.] With respect to prospective and concurrent review requests, each health carrier shall:

and (B) Acknowledge receipt of each nonurgent prospective and SB6concurrent /review Filerequest No.as soon as practicable, but not later than twenty-four hours following such health carrier's receipt of such prospective and concurrent review request, except that such health carrier shall respond in less time if such a response is required by applicable federal law.

337 16 SB6 File No.

337 concurrent review request as soon as practicable, but not later than twenty-four hours following such health carrier's receipt of such prospective and concurrent review request, except that such health carrier shall respond in less time if such a response is required by applicable federal law.

(A) Information sufficient to identify the benefit request or claim involved, including the date of service, if applicable, the health care professionalLCO and4966 the{\\PRDFS1\SCOUSERS\FORZANOF\WS\2023SB-000017 claimof amount;25 R03-SB.docx } Committee Bill No.

6 professional and the claim amount;

(D) A description of any additional material or informationnecessary SB6for /the Filecovered No.person to perfect the benefit request or claim, including anexplanationofwhythematerialorinformationisnecessary to perfect the request or claim;

337 17 SB6 File No.

337 for the covered person to perfect the benefit request or claim, including anexplanationofwhythematerialorinformationisnecessary to perfect the request or claim;

(F) (i) (I) A copy of the specific rule, guideline, protocol or other similar criterion the health carrier relied upon to make the adverse determination, or (II) a statement that a specific rule, guideline, protocol or other similar criterion of the health carrier was relied upon to make the adverse determination and that a copy of such rule, guideline, protocolorothersimilarcriterionwillbeprovidedtothecoveredperson free of charge upon request, with instructions for requesting such copy, and (ii) the links to such rule, guideline, protocol or other similar criterionLCO on4966 such{\\PRDFS1\SCOUSERS\FORZANOF\WS\2023SB-00018 healthof carrier's25 InternetR03-SB.docx web} site;Committee Bill No.

6 criterion on such health carrier's Internet web site;

(H) A statement explaining the right of the covered person to contact SB6the /commissioner's Fileoffice No.or the Office of the Healthcare Advocate at any time for assistance or, upon completion of the health carrier's internal grievance process, to file a civil action in a court of competent jurisdiction.

337 18 SB6 File No.

337 the commissioner's office or the Office of the Healthcare Advocate at any time for assistance or, upon completion of the health carrier's internal grievance process, to file a civil action in a court of competent jurisdiction.

and (I) A statement, expressed in language approved by the Healthcare Advocate and prominently displayed on the first page or cover sheet of the notice using a call-out box and large or bold text, that if the covered person or the covered person's authorized representative chooses to file a grievance of an adverse determination, (i) such appeals are sometimes successful, (ii) such covered person or covered person's authorized representative may benefit from free assistance from the Office of the Healthcare Advocate, which can assist such covered person or covered person's authorized representative with the filing of a grievance pursuant to 42 USC 300gg-93, as amended from time to time, (iii) such covered personor coveredperson'sauthorizedrepresentative isentitled and encouraged to submit supporting documentation for the health carrier's consideration during the review of an adverse determination, including narratives from such covered person or covered person's authorized representative and letters and treatment notes from such covered person's health care professional, and (iv) such covered person or covered person's authorized representative has the right to ask such coveredLCO person's4966 health{\\PRDFS1\SCOUSERS\FORZANOF\WS\2023SB-000019 careof professional25 forR03-SB.docx such} lettersCommittee orBill treatmentNo. notes.

6 covered person's health care professional for such letters or treatment notes.

SB6(2) /An Fileexplanation No.as to why the act, practice or omission was fraudulent or was an intentional misrepresentation of a material fact;

337 19 SB6 File No.

337 (2) An explanation as to why the act, practice or omission was fraudulent or was an intentional misrepresentation of a material fact;

(g) (1) Whenever a health carrier fails to strictly adhere to the requirements of this section with respect to making utilization review and benefit determinations of a benefit request or claim, the covered person shall be deemed to have exhausted the internal grievance process of such health carrier and may file a request for an external review in accordance with the provisions of section 38a-591g, regardless ofLCO whether4966 the{\\PRDFS1\SCOUSERS\FORZANOF\WS\2023SB-000020 health carrier asserts it substantially complied with the requirements of this25 sectionR03-SB.docx or} thatCommittee anyBill errorNo. it committed was de minimis.

6 of whether the health carrier asserts it substantially complied with the requirements of this section or that any error it committed was de minimis.

(a) Each individual health insurance policy delivered, issued for delivery, renewed, amended or continued in this state providing SB6coverage /of Filethe No.type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469 for a family member of the insured or subscriber shall, as to such family member's coverage, also provide that the health insurance benefits applicable for children shall be payable with respect to a newly born child of the insured or subscriber from the moment of birth.

337 20 SB6 File No.

337 coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469 for a family member of the insured or subscriber shall, as to such family member's coverage, also provide that the health insurance benefits applicable for children shall be payable with respect to a newly born child of the insured or subscriber from the moment of birth.

(c) If payment of a specific premium or subscription fee is required to provide coverage for a child, the policy or contract may require that notification of birth of such newly born child and payment of the required premium or fees shall be furnished to the insurer, hospital service corporation, medical service corporation or health care center not later than [sixty-one] one hundred twenty-one days after the date of birth or the date of discharge from the hospital, whichever is later, in order to continue coverage beyond such [sixty-one-day] period, providedLCO failure4966 to{\\PRDFS1\SCOUSERS\FORZANOF\WS\2023SB-0021 furnishof such25 noticeR03-SB.docx or} payCommittee suchBill premiumNo. or fees shall not prejudice any claim originating within such [sixty-one-day] period.

6 provided failure to furnish such notice or pay such premium or fees shall not prejudice any claim originating within such [sixty-one-day] period.

(a) Each group health insurance policy delivered, issued for delivery, renewed, amended or continued in this state providing coverage of the type specifiedin subdivisions(1),(2),(4), (6), (11)and(12) ofsection38a-ofsection 38a- 469 for a family member of the insured or subscriber shall, as to such family member's coverage, also provide that the health insurance benefits applicable for children shall be payable with respect to a newly born child of the insured or subscriber from the moment of birth.

(b) Coverage for such newly born child shall consist of coverage for injury and sickness including necessary care and treatment of medically SB6diagnosed /congenital Filedefects No.and birth abnormalities within the limits of the policy.

337 21 SB6 File No.

337 diagnosed congenital defects and birth abnormalities within the limits of the policy.

(a) No insurance company, hospital service corporation, medical service corporation, health care center or other entity delivering, issuing forLCO delivery,4966 renewing,{\\PRDFS1\SCOUSERS\FORZANOF\WS\2023SB-000022 amendingof or25 continuingR03-SB.docx an} individualCommittee healthBill insuranceNo. policy or contract that provides coverage for prescription drugs may:

6 for delivery, renewing, amending or continuing an individual health insurance policy or contract that provides coverage for prescription drugs may:

[,] or (B) [a] A prescribed drug for [cancer] treatment of a behavioral health 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 SB6compliance /with Fileapproved No.federal Food and Drug Administration indications.

337 22 SB6 File No.

337 compliance with approved federal Food and Drug Administration indications.

Sec.LCO 4966 {\\PRDFS1\SCOUSERS\FORZANOF\WS\2023SB-0023 of 25 R03-SB.docx } Committee Bill No.

6 Sec.

SB6(A) /[any] FileAny No.prescribed drug for longer than sixty days;

337 23 SB6 File No.

337 (A) [any] Any prescribed drug for longer than sixty days;

If such provider does not deem such step therapy drug regimenLCO clinically4966 ineffective{\\PRDFS1\SCOUSERS\FORZANOF\WS\2023SB-0024 or has not requested an override pursuant to subdivision (1) of subsection25 (b)R03-SB.docx of} thisCommittee section,Bill suchNo. drug regimen may be continued.

6 regimen clinically ineffective or has not requested an override pursuant to subdivision (1) of subsection (b) of this section, such drug regimen may be continued.

SB6Section /1 FileOctober No.1, 2023 New section Sec.

337 24 SB6 File No.

337 Section 1 October 1, 2023 New section Sec.

8 October 1, 2023 New section INS Joint Favorable SB6APP /Joint FileFavorable No.LCO 4966 {\\PRDFS1\SCOUSERS\FORZANOF\WS\2023SB-00006- 25 of 25 R03-SB.docx }

337 25 SB6 File No.

337 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 24 $ FY 25 $ State Comptroller - Fringe GF - Potential See Below See Below Benefits Cost UConn Health Ctr.

GF - Potential At Least At Least Cost 100,000 100,000 Note:

GF=General Fund Municipal Impact:

Municipalities Effect FY 24 $ FY 25 $ Various Municipalities Potential See Below See Below Cost Explanation Sections 1 and 3 pertain to:

(1) exemptions, under certain circumstances, for health care providers from certain utilization review processes used by health insurers and HMOs (also known as “gold- carding”) and (2) shortening several of the maximum timeframes for insurers or independent review organizations (IRO) to notify insureds of their utilization review decisions.

These sections do not result in a fiscal impact to the Insurance Department because:

(1) the agency has the capacity and expertise to develop the regulations required by the bill and enforce its provisions, and (2) the bill specifies that the fees for IROs to conduct reviews of adverse determinations for such exemptions must be paid by the health insurer or HMO.

Section 2 could result in a potential cost to the UConn Health Center SB6 / File No.

337 26 SB6 File No.

337 beginning in FY 24, associated with establishing a secure system to electronically receive andrespondtoprospective andconcurrentreview requests.

It is anticipated that the potential costs would exceed $100,000 annually.

Sections 4 and 5 extend the timeframe insurers must provide for notice of the birth of a newborn.

This may result in a fiscal impact to the state and municipal plans to the extent that the number of claims increases.

Sections 6 and 7 eliminate step therapy for certain behavioral health, or chronic, disabling, or life-threatening conditions or diseases resulting in no fiscal impact to the state employee and retiree health plan because step therapy is not frequently used within the plans.

This may impact certain municipal plans that require step therapy.

Section 8 of the bill prohibits the repeated use of utilization review for recurring health care services or prescription drugs.

This decreases health carriers' ability to lower costs and in turn may impact state and municipal health plans through increased premiums.

The Out Years The annualized ongoing fiscal impact identified above would continue into the future subject to inflation.

SB6 / File No.

337 27 SB6 File No.

337 OLR Bill Analysis SB 6 AN ACT CONCERNING UTILIZATION REVIEW AND HEALTH CARE CONTRACTS, HEALTH INSURANCE COVERAGE FOR NEWBORNS AND STEP THERAPY.

SUMMARY This bill makes the following changes in the insurance statutes:

1.

establishes conditions under which health carriers (e.g., insurers and HMOs) must exempt providers from certain utilization review (e.g., prior authorization) based on their approval rates for health care services and treatments over the prior six months;

2.

prohibits health carriers from requiring a prospective or concurrent review of a recurring health care service or prescription drug already approved through utilization review;

3.

requires health carriers to implement a program to electronically receive and respond to certain utilization review requests;

4.

shortens several of the maximum timeframes for health insurers or independent review organizations (IROs) to notify an insured or his or her authorized representative of utilization review decisions;

5.

extends, from 61 days after birth to the later of 121 days after the birth or the hospital discharge date, thetime period within which the insured person must (a) notify the insurer, HMO, or hospital or medical service corporation about the birth and (b) pay any required premium or subscription fee to continue the newborn’s coverage beyond that period;

and SB6 / File No.

337 28 SB6 File No.

337 6.

expands when health carriers are prohibited from requiring that an insured use step therapy to include a prohibition against requiring that step therapy be used for prescribed drugs to treat a behavioral health condition or a disabling, chronic, or life- threatening condition or disease.

EFFECTIVE DATE:

October 1, 2023 § 1 — PROSPECTIVE AND CONCURRENT REVIEW EXEMPTION Exemption Threshold and Notification Broadly, utilization review refers to a process in which health carriers determine whether a specific medical service is reimbursable under an individual’s plan or insurance policy.

Prospective reviews (which occur before a service is provided) and concurrent reviews (which occur while a person is undergoing treatment) are two types of utilization reviews.

In practice, many prospective or concurrent reviews are “prior authorization” reviews, which require a health care provider to obtain approval before a medical service is covered.

Beginning with health care contracts entered into, renewed, or amended on or after January 1, 2024, the bill prohibits health carriers that perform utilization review from requiring that a participating provider obtain a prospective or concurrent review for a specific health care service or course of treatment (i.e., services) if the carrier approved 90%oftheprovider’sreviewsfortheserviceintheprecedingsixmonths (i.e., “evaluation period” as described below).

Under the bill, carriers generally must conduct an evaluation every six months to determine whether providers qualify for this exemption.

However, no participating providers are required to request an exemption in order to qualify for one.

Within five business days after a provider qualifies for an exemption, the health carrier must provide it a written notice that (1) states that it qualifies for an exemption, (2) identifies the exemption’s duration, and (3) lists the provider’s exempt services and health benefit plans to which the exemption applies.

SB6 / File No.

337 29 SB6 File No.

337 Scope of the Evaluation Under the bill, the evaluation that carriers must conduct depends on whether the participating provider has a prospective or concurrent review exemption for the service.

For non-exempt services, the evaluation is a review of the provider’s prospective or concurrent review exemption requests during the most recent evaluation period to (1) determine the percentage ofrequests that were approved or (2) evaluate whether to grant or deny a prospective or concurrent review exemption.

For exempt services, the evaluation is a retrospective review of a randomsampleofthe payableclaims theprovider submittedduring the most recent evaluation period to (1) determine the percentage of claims that would have been approved based on the health carrier’s applicable medical necessity data at the time the service was provided and (2) evaluate whether to continue or rescind the exemption.

Evaluation Period Under the bill, the evaluation period is the six-month period before an evaluation.

For initial exemptions or denials, the evaluation period is any six-month period beginning on January 1 or July 1, 2024, or any subsequent six-month period beginning January or July 1.

After this initial determination, the evaluation period is the six-month period starting on the first day following the end of the evaluation period that the denial or recission was based on.

If an exemption is being rescinded (as described below), the evaluationperiodis thesix-monthperiodafter thehealthcarrier notifies the provider of the rescission.

However, no more than two months may elapse between the end of this evaluation period and the date the provider receives the notice.

Length of Exemption Under the bill, a participating provider’s exemption remains in effect until 30 days after the health carrier notifies it of a decision to rescind the exemption unless the provider appeals.

In that case, the exemption SB6 / File No.

337 30 SB6 File No.

337 is in effect until the five days after the IRO (see below) affirms the health carrier’s decision.

Under the bill, if a health carrier does not finalize a rescission determination, the provider automatically qualifies for an exemption.

(The bill does not specify how a recission determination is “finalized.”) Providers Submitting Exemption Eligible Claims Under the bill, carriers must notify providers if they submit a claim for a health service which qualifies for an exemption.

Specifically, a carrier must promptly provide a written notice that (1) states that the provider qualifies for an exemption, (2) identifies the exemption’s duration, (3) lists the provider’s exempt services and health benefit plans to which the exemption applies, and (4) describes the carrier’s payment requirements.

Rescissions The bill allows health carriers to rescind a participating provider’s exemption only during the following time periods and under the following circumstances:

1.

during January or July of each year;

2.

if it determines, based on a retrospective review of a random sample of between five and 20 claims submitted by the provider during the most recent evaluation period, that less than 90% of the claims for health care services or treatments met the medical necessity criteria the carrier would have used to evaluate the claims;

and 3.

if it notifies the provider in writing at least 30 days before the recission is effective and includes (a) the sample information it used to make the determination and (b) a plain language description of the appeal and independent review process (see below).

Exemption Denials SB6 / File No.

337 31 SB6 File No.

337 The bill prohibits carriers from denying exemptions unless they provide the participating provider the statistics, data, and other information sufficient to demonstrate that the provider failed to meet the exemption criteria for each health care service or treatment.

Independent Review Process IRO Request and Timeline.

The bill establishes a process for providers to appeal a carrier’s decision to rescind an exemption with an IRO.

It allows a provider to request that an IRO review a health carrier’s decision to rescind an exemption.

It additionally prohibits carriers from requiring that a provider engage in an internal review process before requesting a review of an adverse determination of an exemption.

(Presumably, an adverse determination is a determination that an exemption should be rescinded.) IROs must complete the review within calendar days of when the provider files the request.

The participating provider may request that the IRO consider a random sample of between five and 20 claims it submitted to the health carrier for the specified health service or treatment during the evaluation period that led to the recission.

If the provider requests this, the IRO must base its determination on the medical necessity of the same claims that the insurer used in rescinding the exemption.

IRO determinations are binding on the carrier and the provider, except to the extent to which either party has other remedies available under state or federal law.

Fees.

The billrequireshealth carriersissuing adverse determinations of a provider’s exemption (presumably a recission) must pay (1) the IRO for the cost of conducting the review and (2) reasonable fees for copies of all documents, communication, information, and evidence relating to theadversedetermination.Thebillrequirestheinsurancecommissioner to adopt regulations to implement these fees.

Overturned Determinations.

If an IRO overturns a health carrier’s determination of an exemption, the carrier (1) cannot attempt to rescind the exemption before the end of the next evaluation period and (2) may SB6 / File No.

337 32 SB6 File No.

337 only rescind the exemption if it complies with the bill’s notification and other recission requirements described above.

Reconsideration Under the bill, a provider who has had an exemption denied or rescinded is eligible for reconsideration at the end of the six-month evaluation period that follows the one that formed the basis for the recission or denial.

Patient and Provider Protections The bill prohibits health carriers from retroactively denying services because a provider’s exemption was rescinded, even if the rescission was affirmed by an IRO.

It also prohibits carriers from denying or reducing a payment to a provider for a service for which it qualified for an exemption based on medical necessity or appropriateness of care except in certain cases of fraud (i.e., the provider knowingly and materially misrepresented the service in a claim submitted to the health carrier or failed to substantially perform it).

Additionally, the bill prohibits health carriers from retrospectively reviewing a service (presumably for a particular health care provider) that is subject to an exemption except (1) to determine if a provider qualifies for an exemption or (2) if they have reasonable cause to believe that the provider knowingly and materially misrepresented the service or failed to substantially perform it.

Regulations The bill requires the insurance commissioner to adopt regulations implementing the exemption provisions.

§ 2 — ELECTRONIC PRIOR AUTHORIZATIONS By January 1, 2024, the bill requires health carriers to establish a secure system to electronically receive and respond to prospective and concurrent review requests and other requests for prospective or concurrent utilization reviews, including supporting clinical information, submitted by hospitals and health care professionals.

SB6 / File No.

337 33 SB6 File No.

337 § 3 — UTILIZATION REVIEW REQUEST TIME FRAMES Existing law establishes a structure and timeframe for health carriers and IROs to conduct benefit reviews and notify a covered individual whether a specific medical service is reimbursable by his or her health insurance plan.

The bill shortens several of the maximum timeframes a health insurer or IRO can take, after receiving all the required health information, to notify an insured or the insured’s authorized representative of decisions.

Specifically, the bill shortens the maximum response time for decisions about the following requests:

1.

a non-urgent prospective or concurrent review request, from 15 calendar days to 72 hours;

2.

a one-time extension of non-urgent prospective or concurrent reviewrequestsduetocircumstancesbeyondthecarrier’scontrol and following proper notice, from 15 calendar days to 72 hours;

3.

urgent care requests, from 48 hours (or 72 hours if the request or response time falls on a weekend) to 24 hours.

By law, urgent review requests must be done as soon as possible, taking into account the insured’s medical condition.

Notification and Processing The bill also changes how a health carrier must process incomplete review requests.

Under current law, a health carrier must notify an insured and the insured’s authorized representative within five calendar days of a request that does not meet the carrier’s filing requirements (or within 24 hours for an urgent care request).

Under the bill for prospective and concurrent review requests, a carrier must instead (1) process requests 24 hours a day, seven days a week, including holidays and (2) acknowledge receipt of these requests as soon as practicable and within 24 hours unless federal law requires a faster response.

SB6 / File No.

337 34 SB6 File No.

337 Current law allows health carriers to notify patients orally, so long as a written notice follows.

The bill repeals this explicit authorization.

Additionally, the bill prohibits health carriers from requiring that health care professionals or hospitals submit additional information with a prospective or concurrent review that is not reasonably available at the time the request is submitted.

§§ 4 & 5 — NEWBORN HEALTH INSURANCE COVERAGE By law, certain health insurance policies that cover family members must cover newborns from birth.

The coverage must include injury and sickness benefits, including the care and treatment of congenital defects and birth abnormalities.

The bill extends, from 61 days after birth to the later of 121 days after the birth or the hospital discharge date, the time period within which the insured person must (1) notify the insurer, HMO, or hospital or medical service corporation about the birth and (2) pay any required premium or subscription fee to continue the newborn’s coverage beyond that period.

As under current law, if notification and payment is not provided within the specified period, claims originating during that period are not prejudiced.

The bill applies to individual and group health insurance policies delivered, issued, renewed, amended, or continued in Connecticut that cover (1)basichospitalexpenses;(2)basicmedical-surgicalexpenses;(3) major medical expenses;

(4) accidents;

or (5) hospital or medical services, including those provided under an HMO plan.

It also applies to individual health insurance policies that cover limited benefits.

Because of the federal Employee Retirement Income Security Act, state insurance benefit mandates do not apply to self-insured benefit plans.

§§ 6 & 7 — STEP THERAPY PROHIBITIONS Step therapy is a protocol for establishing the sequence for prescribing drugs for specific medical conditions;

it generally requires patients to try less expensive drugs before higher cost drugs.

The bill prohibits individual and group health insurers from requiring an SB6 / File No.

337 35 SB6 File No.

337 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.

§ 8 — PROHIBITION ON REVIEWS OF RECURRING HEALTH CARE SERVICES AND PRESCRIPTION DRUGS The bill prohibits health carriers from requiring a prospective or concurrent reviewofarecurring healthcare service or prescriptiondrug after they have certified the service or drug through utilization review.

The bill specifies that it doesnot require ahealthcarrier to cover ahealth care service or prescription drug that a policy’s coverage conditions completely exclude for a specific health condition.

COMMITTEE ACTION Insurance and Real Estate Committee Joint Favorable Yea 7 Nay 5 (03/14/2023) SB6 / File No.

337 36