Connecticut 2024 Regular Session Status: In Committee Bipartisan · 4 D · 1 R cosponsors

SB 180 — AN ACT CONCERNING ADVERSE DETERMINATION AND UTILIZATION REVIEWS.

Last action — FILE NO. 18

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

This bill died with 2024 Regular Session. It reached “In Committee” 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This bill is no longer active — its legislative session has ended, so there are no live odds of enactment. It would have to be reintroduced in the current session to move again.

Bill Text

What changed in the latest version

156 added · 29 removed

156 line(s) added, 29 removed.

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General Assembly Raised Bill No.
Senate General Assembly File No.
180 February Session, 2024 LCO No.
18 February Session, 2024 Senate Bill No.
1486 Referred to Committee on PUBLIC HEALTH Introduced by:
180 Senate, March 13, 2024 The Committee on Public Health reported through SEN.
(PH) AN ACT CONCERNING ADVERSE DETERMINATION AND UTILIZATION REVIEWS.
ANWAR of the 3rd Dist., Chairperson of the Committee on the part of the Senate, that the bill ought to pass.
AN ACT CONCERNING ADVERSE DETERMINATION AND UTILIZATION REVIEWS.
(A)[holds]Forareviewotherthanonespecifiedundersubparagraph (B) or (C) of subdivision (38) of this section, holds a nonrestricted license in a state of the United States [and] in the same [or similar] specialty as [typically manages the medical condition, procedure or treatment] the treatingphysicianorotherhealthcareprofessional underreview;[,and] or (B) [for] For a review specified under subparagraph (B) or (C) of subdivision (38) of this section concerning:
(A)[holds]Forareviewotherthanonespecifiedundersubparagraph (B) or (C) of subdivision (38) of this section, holds a nonrestricted license in a state of the United States [and] in the same [or similar] specialty as [typically manages the medical condition, procedure or treatment] the treatingphysicianorotherhealthcareprofessional underreview;[,and] or (B) [for] For a review specified under subparagraph (B) or (C) of SB180 / File No.
LCO 1486 \\PRDFS1\SCOUSERS\FORZANOF\WS\2024SB-00180-R01 of 8 SB.docx Bill No.
18 1 SB180 File No.
180 (i) [a] A child or adolescent substance use disorder or a child or adolescent mental disorder, holds (I) a national board certification in child and adolescent psychiatry, or (II) a doctoral level psychology degree with training and clinical experience in the treatment of child and adolescent substance use disorder or child and adolescent mental disorder, as applicable;
18 subdivision (38) of this section concerning:
(i) [a] A child or adolescent substance use disorder or a child or adolescent mental disorder, holds (I) a national board certification in child and adolescent psychiatry, or (II) a doctoral level psychology degree with training and clinical experience in the treatment of child and adolescent substance use disorder or child and adolescent mental disorder, as applicable;
(C) Each health carrier shall (i) post on its Internet web site (I) any LCO 1486 {\\PRDFS1\SCOUSERS\FORZANOF\WS\2024SB-001802 of 8 R01-SB.docx } Bill No.
SB180 / File No.
180 clinical review criteria it uses, and (II) links to any rule, guideline, protocolorothersimilarcriterionahealthcarriermayrelyupontomake an adverse determination as described in subparagraph (F) of subdivision (1) of subsection (e) of section 38a-591d, and (ii) make its clinicalreviewcriteriaavailableuponrequest toauthorizedgovernment agencies.
18 2 SB180 File No.
18 (C) Each health carrier shall (i) post on its Internet web site (I) any clinical review criteria it uses, and (II) links to any rule, guideline, protocolorothersimilarcriterionahealthcarriermayrelyupontomake an adverse determination as described in subparagraph (F) of subdivision (1) of subsection (e) of section 38a-591d, and (ii) make its clinicalreviewcriteriaavailableuponrequest toauthorizedgovernment agencies.
Any such clinical review criteria developed by a health carrier or purchased or licensed from a qualified vendor shall conform to the requirements of subparagraph (A) of subdivision (2) of this LCO 1486 {\\PRDFS1\SCOUSERS\FORZANOF\WS\2024SB-00183 of 8 R01-SB.docx } Bill No.
Any such clinical review criteria developed by a health carrier or purchased or licensed from a qualified vendor shall conform to the requirements of subparagraph (A) of subdivision (2) of this SB180 / File No.
180 subsection.
18 3 SB180 File No.
18 subsection.
or (B) clinical review criteria that the health carrier demonstrates to the Insurance Department is consistent with the most recent guidelines of the American Psychiatric Association or the most recent Standards and Guidelines of the Association for Ambulatory Behavioral Healthcare, 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 an LCO 1486 {\\PRDFS1\SCOUSERS\FORZANOF\WS\2024SB-00184 of 8 R01-SB.docx } Bill No.
or (B) clinical review criteria that the health carrier demonstrates to the Insurance Department is consistent with the most recent guidelines of the American Psychiatric Association or the most recent Standards and Guidelines of the Association for Ambulatory Behavioral Healthcare, 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 an adult mental disorder,that are not covered inthe most recent guidelines SB180 / File No.
180 adult mental disorder,that are not covered inthe most recent guidelines of the American Psychiatric Association or the most recent Standards and Guidelines of the Association for Ambulatory Behavioral Healthcare.
18 4 SB180 File No.
18 of the American Psychiatric Association or the most recent Standards and Guidelines of the Association for Ambulatory Behavioral Healthcare.
(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 LCO 1486 {\\PRDFS1\SCOUSERS\FORZANOF\WS\2024SB-001805 of 8 R01-SB.docx } Bill No.
(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 SB180 / File No.
180 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.
18 5 SB180 File No.
18 adverse determination as long as a grievance has not been filed as set forth in subparagraph (B) of this subdivision.
(C)(i)Foreachreviewofanadversedeterminationunderthissection, there shall be a rebuttable presumption that each health care service under review is medically necessary if such health care service was LCO 1486 {\\PRDFS1\SCOUSERS\FORZANOF\WS\2024SB-00180-6 of 8 R01-SB.docx } Bill No.
(C)(i)Foreachreviewofanadversedeterminationunderthissection, there shall be a rebuttable presumption that each health care service under review is medically necessary if such health care service was ordered by a health care professional acting within the scope of the health care professional's practice.
180 ordered by a health care professional acting within the scope of the health care professional's practice.
The health carrier may rebut such presumption by reasonably substantiating to the clinical peer or peers SB180 / File No.
The health carrier may rebut such presumption by reasonably substantiating to the clinical peer or peers conducting the review under this section that such health care service is not medically necessary.
18 6 SB180 File No.
18 conducting the review under this section that such health care service is not medically necessary.
(3) If the review under subdivision (1) of this subsection is an expedited review of a grievance involving an adverse determination of LCO 1486 {\\PRDFS1\SCOUSERS\FORZANOF\WS\2024SB-00187 of 8 R01-SB.docx } Bill No.
(3) If the review under subdivision (1) of this subsection is an expedited review of a grievance involving an adverse determination of a concurrent review request, pursuant to 45 CFR 147.136, as amended from time to time, the treatment shall be continued without liability to the covered person until the covered person has been notified of the review decision.
180 a concurrent review request, pursuant to 45 CFR 147.136, as amended from time to time, the treatment shall be continued without liability to the covered person until the covered person has been notified of the review decision.
SB180 / File No.
This act shall take effect as follows and shall amend the following sections:
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18 This act shall take effect as follows and shall amend the following sections:
4 January 1, 2025 38a-591e(c) PH Joint Favorable LCO 1486 {\\PRDFS1\SCOUSERS\FORZANOF\WS\2024SB-00180- 8 of 8 R01-SB.docx }
4 January 1, 2025 38a-591e(c) PH Joint Favorable SB180 / File No.
18 8 SB180 File No.
18 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 25 $ FY 26 $ State Comptroller - Fringe GF - Potential Potential Potential Benefits Cost UConn Health Ctr.
GF - Potential Potential Potential Clinical Revenue Gain Note:
GF=General Fund Municipal Impact:
Municipalities Effect FY 25 $ FY 26 $ Various Municipalities Potential See Below See Below Cost Explanation The bill results in a potential cost to the State Comptroller – Fringe Benefits account for the state employee health plan from the anticipated increase in administrative costs and utilization of medical services.
Administrative costs are expected to increase from the redefinition of "clinical peer," which would require carriers to contract specialists at a rate of approximately $700 per adverse determination.
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Claims costs are also expected to increase as more medical services are deemed, "medically necessary" resulting from the change in utilization review methodology.
Self and fully insured municipalities as well as those enrolled in the Partnership plan are likely to see an increase in premiums to the extent carriers expect to see higher utilization of services and face higher costs for evaluating adverse determination appeals.
Due to federal law, self- SB180 / File No.
18 9 SB180 File No.
18 insured health plans are exempt from state health insurance benefit mandates, so potential costs are contingent on the plan electing to adopt the mandate.
To the extent that the bill results in additional medical services provided by the University of Connecticut Health Center, there could be a clinical revenue increase beginning in FY 25.
The scope of the revenue increase would be dependent upon the type and number of additional services.
The Out Years The annualized ongoing fiscal impact identified above would continue into the future subject to inflation.
Sources:State Employee Health Plan Provider SB180 / File No.
18 10 SB180 File No.
18 OLR Bill Analysis SB 180 AN ACT CONCERNING ADVERSE DETERMINATION AND UTILIZATION REVIEWS.
SUMMARY For insurance utilization or adverse determination reviews, this bill establishes a rebuttable presumption that a health care service is medically necessary if it was ordered by a health professional acting within his or her scope of practice (see BACKGROUND).
For utilization reviews, the bill imposes on health carriers or utilization review companies the burden of proving a health care service is not medically necessary.
For adverse determination reviews, a carrier may rebut the presumptionby reasonably substantiating to theclinicalpeers doing the review that the service is not medically necessary.
(Utilization and adverse determination reviews are steps in determining whether a specific service is covered and reimbursed.) The bill generally increases the requirements to qualify as a “clinical peer” for adverse determination reviews, by requiring the person to be licensed in the same specialty, rather than a similar one, as the professional under review.
(It does not change existing, generally comparable requirements that apply in cases involving the urgent treatment of substance use or mental disorders.) The bill also requires health carriers to authorize clinical peers to reverse initial adverse determinations that were based on medical necessity.
This applies when the carrier, as required by law, offers a covered person’shealthcare professionalthe opportunity to conferwith a clinical peer of the carrier following the adverse determination (see BACKGROUND).
SB180 / File No.
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18 EFFECTIVE DATE:
January 1, 2025 § 1 — CLINICAL PEER QUALIFICATIONS Under current law, clinical peers doing adverse determination reviews generally must have a nonrestricted license (in any U.S.
state) in the same or similar specialty that typically manages the medical condition, procedures, or treatment under review.
The bill instead generally requires these clinical peers to have a nonrestricted license in the same specialty as the treating physician or other health care professional under review.
By law, unchanged by the bill, for urgent care requests of substance use or mental health disorders under certain circumstances, the clinical peer must be a (1) psychologist with relevant training and clinical experience or (2) psychiatrist.
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, whichisdone whena coveredpersonexhaustsahealthcarrier’sinternal processandappealsthecarrier’sadverse determinationto the Insurance Department.
External reviews, also called final adverse determination reviews, are done by an independent review organization assigned by the department.
Medically Necessary State law specifies the definition of “medically necessary” that health policies must include.
In general, a health care service is medically necessary if it would be provided by a physician exercising prudent clinical judgment for the purposes of preventing, evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms, and it is:
SB180 / File No.
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18 1.
in keeping with generally accepted medical standards;
2.
clinically appropriate and considered effective for the illness, injury, or disease;
3.
not primarily for the convenience of the patient, physician, or other health care provider;
and 4.
not more costly than therapeutically equivalent alternative treatments (CGS §§ 38a-482a and 38a-513c).
Conference With Clinical Peer Following Adverse Determination The law requires a carrier to offer a covered person’s health care professional an opportunity to confer with a clinical peer of the carrier under certain circumstances.
This applies:
1.
after a covered person or his or her representative or health care professional is notified of an initial adverse determination of a concurrent or prospective utilization review, or of a benefit request, that wasat least partially basedonmedicalnecessity and 2.
as long as the covered person, representative, or health care professional has not already filed a grievance of the initial adverse determination.
COMMITTEE ACTION Public Health Committee Joint Favorable Yea 30 Nay 7 (03/04/2024) SB180 / File No.
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Action History

  1. FILE NO. 18

  2. SENATE CALENDAR NUMBER 43

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

  4. RPTD. OUT OF LCO

  5. REFERRED TO Office of Legislative Research AND Office of Fiscal Analysis 03/12/24

  6. FILED WITH LCO

  7. Joint Favorable

  8. PUBLIC HEARING 0226

  9. REF. TO JOINT COMM. ON Public Health

Sponsors

Sponsorship breakdown

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5 sponsors · 0 co-sponsors · 182 not signed on

Sponsors (5)

Co-sponsors (0)

None.

Not signed on (182)

182 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 180?
SB 180 is sponsored by Martin M. Looney (Democratic), Jeff Gordon (Republican), Saud Anwar (Democratic), Julie Kushner (Democratic), and Rick Lopes (Democratic).
What is the current status of SB 180?
This bill died with 2024 Regular Session. It reached “In Committee” 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 180?
Track SB 180 free on One Click Politics — get push/email alerts when it moves.

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