SB 10 — AN ACT CONCERNING HEALTH INSURANCE AND PATIENT PROTECTION.

or (B) clinical review criteria that the health carrier demonstrates to the Insurance Department is consistent with the most recent guidelines of the American Academy of Child and Adolescent Psychiatry's Child and Adolescent Service Intensity Instrument, 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 child or adolescent mental disorder, that are not covered in the most recent guidelines of the American Academy of LCO 6 of 26 Substitute Bill No.

10 Child and Adolescent Psychiatry's Child and Adolescent Service Intensity Instrument.

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 subsection.

(5) For any utilization review for the treatment of an adult mental disorder, the clinical review criteria used shall be:

(A) The most recent guidelines of the American Psychiatric Association or the most recent StandardsandGuidelinesofthe Associationfor Ambulatory Behavioral Healthcare;

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 of the American Psychiatric Association or the most recent Standards and Guidelines of the Association for Ambulatory Behavioral Healthcare.

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 subsection.

(b) Each health carrier shall:

(1) Have procedures in place to ensure that (A) the health care professionals administering such health carrier's utilization review program are applying the clinical review criteria consistently in utilization review determinations, and (B) the appropriate or required individual or individuals are being designated to conduct utilization reviews;

LCO 7 of 26 Substitute Bill No.

10 (2) Have data systems sufficient to support utilization review program activities and to generate management reports to enable the health carrier to monitor and manage health care services effectively;

(3) Provide covered persons and participating providers with access to its utilization review staff through a toll-free telephone number or any other free calling option or by electronic means;

(4) Coordinate the utilization review program with other medical management activity conducted by the health carrier, such as quality assurance, credentialing, contracting with health care professionals, data reporting, grievance procedures, processes for assessing member satisfaction and risk management;

[and] (5) Routinely assess the effectiveness and efficiency of its utilization review program;

and (6) Not use any system that employs artificial intelligence, as defined in section 51-10e, or any other algorithm in lieu of a review by a clinical peer to evaluate the clinical appropriateness of an adverse determination pursuant to a contract between such clinical peer and such health carrier.

Sec.

6.

Subsection (c) of section 38a-591e of the general statutes is repealedandthefollowingissubstitutedinlieuthereof(EffectiveJanuary 1, 2026):

(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.

(B) If the adverse determination involves utilization review, the health carrier shall designate an appropriate clinical peer or peers to review such adverse determination.

Such clinical peer or peers shall not have been involved in the initial adverse determination.

(C) (i) To effectuate the rebuttable presumption pursuant to LCO 8 of 26 Substitute Bill No.

10 subparagraph(D)ofsubdivision(2)ofsubsection(a)ofsection38a-591c, as amended by this act, the health carrier may rebut such presumption by reasonably substantiating to the clinical peer or peers conducting the review pursuant to the provisions of this section that such health care service is not medically necessary.

[(C)] (ii) The clinical peer or peers conducting a review under this section shall take into consideration all comments, documents, records and other information relevant to the covered person's benefit request that is the subject of the adverse determination under review, that are submitted by the covered person or the covered person's authorized representative, regardless of whether such information was submitted or considered in making the initial adverse determination.

(D) Prior to issuing a decision, the health carrier shall provide free of charge, by facsimile, electronic means or any other expeditious method available, to the covered person or the covered person's authorized representative, as applicable, any new or additional documents, communications, information and evidence relied upon and any new or additional scientific or clinical rationale used by the health carrier in connection with the grievance.

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.

(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.

(3) If the review under subdivision (1) of this subsection is an expedited review of a grievance involving an adverse determination of LCO 9 of 26 Substitute Bill No.

10 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.

Sec.

7.

or (2) Require, if such insurance company, hospital service corporation, medical service corporation, health care center or other entity uses step therapy for such drugs, the use of step therapy (A) for any prescribed drug for longer than [thirty]thirty twenty days, (B) for a prescribed drug for [cancercancer treatment for an insured who has been diagnosed with stage IV metastatic cancer]cancer, themultiple treatmentsclerosis of a disabling or life-threateningrheumatoid chronicarthritis, disease or condition, provided such prescribed drug is in compliance with approved federal Food and Drug Administration indications, [or]or (C) for[for the period commencing January 1, 2024, andandending ending January 1, 2027,2027,inclusive,] inclusive, for thethetreatment treatment of schizophrenia, major depressive disorder or bipolar disorder, as defined in the most recent editionoftheAmericanPsychiatricAssociation's"Diagnosticedition and Statistical Manual of Mentalthe Disorders",American orPsychiatric (D)Association's for"Diagnostic aand prescribedStatistical drugManual for the treatment of aMental mentalDisorders". or behavioral health condition, provided such prescribed drug is in compliance with approved federal Food and Drug Administration indications.

(3)Public AtAct the expiration of the time period specified in subparagraph (A) of subdivision (2) of this subsection or for a prescribed drug described LCO 10 of 26 Substitute Bill No.

1025-94 in5 [subparagraph (B) or (C)] subparagraphs (B) to (D), inclusive, of subdivision24 (2)Substitute ofSenate thisBill subsection,No. an insured's treating health care provider may deem such step therapy drug regimen clinically ineffective for the insured, at which time the insurance company, hospital service corporation, medical service corporation, health care center or other entity shall authorize dispensation of and coverage for the drug prescribed by the insured's treating health care provider, provided such drug is a covered drug under such policy or contract.

10 (3) At the expiration of the time period specified in subparagraph (A) of subdivision (2) of this subsection or for a prescribed drug described in subparagraph (B) or (C) of subdivision (2) of this subsection, an insured's treating health care provider may deem such step therapy drug regimen clinically ineffective for the insured, at which time the insurance company, hospital service corporation, medical service corporation, health care center or other entity shall authorize dispensation of and coverage for the drug prescribed by the insured's treating health care provider, provided such drug is a covered drug under such policy or contract.

For purposesofthissection,"steptherapy"meansaprotocolorpurposes of this section, "step therapy" means a protocol or program that establishes the specific sequence in which prescription drugs for a specified medical condition are to be prescribed.

(b) (1) Notwithstanding the [sixty-day] twenty-daythirty-day period set forth in subparagraph (A) of subdivision (2) of subsection (a) of this section, each insurance company, hospital service corporation, medical service corporation, health care center or other entity that uses step therapy for such prescription drugs shall establish and disclose to its health care providers a process by which an insured's treating health care provider may request at any time an override of the use of any step therapy drug regimen.

Any such override process shall be convenient to use by health care providers and an override request shall be expeditiously granted when an insured's treating health care provider demonstrates that the drug regimen required under step therapy (A) has been ineffective in the past for treatment of the insured's medical condition, (B) is expected to be ineffective based on the known relevant physical or mental characteristics of the insured and the known characteristics of the drug regimen, (C) will cause or will likely cause an adverse reaction by or physical harm to the insured, or (D) is not in the best interest of the insured,Public basedAct onNo. medical necessity.

(2)25-94 Upon6 the granting of an24 override request,the insurance company, hospital service corporation, medical service corporation, health care center or other entity shall authorize dispensation of and coverage for LCO 11 of 26 Substitute Senate Bill No.

10 theinsured, drugbased prescribedon bymedical thenecessity. insured's treating health care provider, provided such drug is a covered drug under such policy or contract.

(c)(2) NothingUpon inthe thisgranting sectionof shallan (1)override precluderequest,the aninsurance insuredcompany, orhospital anservice insured'scorporation, treatingmedical service corporation, health care providercenter fromor requestingother aentity reviewshall underauthorize sectionsdispensation 38a-591cof toand 38a-591g,coverage inclusive,for asthe amendeddrug prescribed by thisthe act,insured's ortreating (2)health affectcare theprovider, provisionsprovided ofsuch sectiondrug 38a-492i.is a covered drug under such policy or contract.

(c) Nothing in this section shall (1) preclude an insured or an insured's treating health care provider from requesting a review under sections 38a-591c to 38a-591g, inclusive, or (2) affect the provisions of section 38a-492i.

8.5.

or (2) Require, if such insurance company, hospital service corporation, medical service corporation, health care center or other entity uses step therapy for such drugs, the use of step therapy (A) for any prescribed drug for longer than [thirty]thirty twenty days, (B) for a prescribed drug for [cancercancer treatment for an insured who has been diagnosed with stage IV metastatic cancer]cancer, themultiple treatmentsclerosis of a disabling or life-threateningrheumatoid chronicarthritis, disease or condition, provided such prescribed drug is in compliance with approved federal Food and Drug Administration indications, [or]or (C) for[for the period commencing January 1, 2024, andandending ending January 1, 2027,2027,inclusive,] inclusive, for thethetreatment treatmentPublic ofAct schizophrenia,No. major depressive disorder or bipolar disorder, as defined in the most recent editionoftheAmericanPsychiatricAssociation's"Diagnostic and Statistical Manual of Mental Disorders", or (D) for a prescribed drug for the treatment of a mental or behavioral health condition, provided such prescribed drug is in compliance with approved federal Food and Drug Administration indications.

LCO25-94 127 of 2624 Substitute Senate Bill No.

10 (3) At the expiration of theschizophrenia, timemajor perioddepressive specifieddisorder in subparagraph (A) of subdivision (2) of this subsection or forbipolar adisorder, prescribedas drugdefined described in [subparagraphthe (B)most orrecent (C)]edition subparagraphs (B) to (D), inclusive, of subdivision (2) of this subsection, an insured's treating health care provider may deem such step therapy drug regimen clinically ineffective for the insured,American atPsychiatric whichAssociation's time"Diagnostic theand insuranceStatistical company,Manual hospital service corporation, medical service corporation, health care center or other entity shall authorize dispensation of andMental coverageDisorders". for the drug prescribed by the insured's treating health care provider, provided such drug is a covered drug under such policy or contract.

(3) At the expiration of the time period specified in subparagraph (A) of subdivision (2) of this subsection or for a prescribed drug described in subparagraph (B) or (C) of subdivision (2) of this subsection, an insured's treating health care provider may deem such step therapy drug regimen clinically ineffective for the insured, at which time the insurance company, hospital service corporation, medical service corporation, health care center or other entity shall authorize dispensation of and coverage for the drug prescribed by the insured's treating health care provider, provided such drug is a covered drug under such policy or contract.

For purposesofthissection,"steptherapy"meansaprotocolorpurposes of this section, "step therapy" means a protocol or program that establishes the specific sequence in which prescription drugs for a specified medical condition are to be prescribed.

(b) (1) Notwithstanding the [sixty-day] twenty-daythirty-day period set forth in subparagraph (A) of subdivision (2) of subsection (a) of this section, each insurance company, hospital service corporation, medical service corporation, health care center or other entity that uses step therapy for such prescription drugs shall establish and disclose to its health care providers a process by which an insured's treating health care provider may request at any time an override of the use of any step therapy drug regimen.

Any such override process shall be convenient to use by health care providers and an override request shall be expeditiously granted when an insured's treating health care provider demonstrates that the drug regimen required under step therapy (A) has been ineffective in the past for treatment of the insured's medical condition, (B) is expected toPublic beAct ineffectiveNo. based on the known relevant physical or mental characteristics of the insured and the known characteristics of the drug regimen, (C) will cause or will likely cause an adverse reaction by or physical harm to the insured, or (D) is not in the best interest of the insured, based on medical necessity.

(2)25-94 Upon8 the granting of an24 override request,the insurance company, LCO 13 of 26 Substitute Senate Bill No.

10 hospitalto servicebe corporation,ineffective medicalbased serviceon corporation,the healthknown carerelevant centerphysical or othermental entitycharacteristics shallof authorizethe dispensationinsured of and coveragethe forknown characteristics of the drug prescribedregimen, by(C) thewill insured'scause treatingor healthwill carelikely provider,cause providedan suchadverse drugreaction isby aor coveredphysical drugharm underto suchthe policyinsured, or contract.(D) is not in the best interest of the insured, based on medical necessity.

(c)(2) NothingUpon inthe thisgranting sectionof shallan (1)override precluderequest,the aninsurance insuredcompany, orhospital anservice insured'scorporation, treatingmedical service corporation, health care providercenter fromor requestingother aentity reviewshall underauthorize sectionsdispensation 38a-591cof toand 38a-591g,coverage inclusive,for asthe amendeddrug prescribed by thisthe act,insured's ortreating (2)health affectcare theprovider, provisionsprovided ofsuch sectiondrug 38a-518i.is a covered drug under such policy or contract.

(c) Nothing in this section shall (1) preclude an insured or an insured's treating health care provider from requesting a review under sections 38a-591c to 38a-591g, inclusive, or (2) affect the provisions of section 38a-518i.

96. (NEW) (Effective July 1, 2026) (a) Each insurer, health care center, hospital service corporation, medical service corporation, preferred provider network or other entity that enters into, renews or amends a contract with a health care provider on or after July 1, 2026, to provide covered benefits to insureds or enrollees in this state shall include in such contract:

(1)Subsection A(b) provisionof requiringsection such38a-481 insurer,of healththe caregeneral center,statutes hospitalis servicerepealedandthefollowingissubstitutedinlieuthereof(EffectiveJanuary corporation,1, medical2027): service corporation, preferred provider network or other entity to:

(A)(b) ReimburseNo therate contractingfiled healthunder carethe providerprovisions forof asubsection covered(a) outpatientof benefitthis thatsection usesshall abe currenteffective proceduraluntil terminologyit evaluationhas andbeen managementapproved (CPTby E/M)the code,commissioner current procedural terminology assessment and management (CPT A/M) code or drug infusion code in anaccordance amountwith thatregulations doesadopted notpursuant varyto basedthis onsubsection. the facility where the contracting health care provider provides such benefit;

andThe (B)commissioner Useshall equaladopt reimbursementregulations, rates for all contracting health care providers in the same geographic region, as determined by the Insurance Commissioner, in accordance with the provisions of chapter 5454, ofto theprescribe generalstandards statutes,to andensure regardlessthat of the employer or affiliation of any contracting health care provider, for each covered outpatient benefit described in subparagraph (A) of this subdivision if the reimbursement for such coveredrates outpatientshall benefitnot isbe madeexcessive, oninadequate a fee-for- benefitbasisoronthebasisofbundledbenefitsperdiagnosis,condition, procedure or anotherunfairly standardizeddiscriminatory. bundle of health care benefits;

andThe LCOcommissioner 14may disapprove such rate if it fails to comply with such standards, except that no rate filed under the provisions of 26subsection Substitute(a) Billof No.this section for any Medicare supplement policy shall be effective unless approved in accordance with section 38a-474.

10If (2)the Acommissioner conspicuousdetermines statement that sucha contracthealth compliescarrier's withaverage premium rate increase, as approved by the provisionscommissioner, ofexceeded subdivisionthe (1)health ofcare thiscost subsection.growth benchmark established pursuant to section 19a-754g for Public Act No.

(b)25-94 The9 Insurance Commissioner shall adopt regulations, in accordance with the provisions of chapter24 54Substitute ofSenate theBill generalNo. statutes, to implement the provisions of this section, including, but not limited to, the establishment of geographic regions pursuant to the provisions of subparagraph (B) of subdivision (1) of subsection (a) of this section.

10 each of the two most recent plan years for which such health care cost growthbenchmark data isavailable, thecommissioner may reduce such health carrier's requested rate filed under the provisions of subsection (a) of this section by not more than two percentage points of such premium rate filed in addition to any other rate reductions authorized under this title.

10.7.

SubsectionsSubsection (a) to (c), inclusive, of section 38a-48138a-513 of the general statutes are repealed and the following is substitutedrepealedandthefollowingissubstitutedinlieuthereof(EffectiveJanuary in lieu thereof (Effective January 1, 2026):2027):

(a) (1) No individualgroup health insurance policypolicy, shallas bedefined deliveredby orthe issuedcommissioner, foror deliverycertificate to any person in this state, nor shall anybe application,delivered rider or endorsementissued befor useddelivery in connectionthis withstate suchunless policy, until a copy of the form thereoffor andsuch ofpolicy theor classificationcertificate ofhas risksbeen submitted to and approved by the premiumcommissioner ratesunder havethe beenregulations filedadopted withpursuant theto commissioner.this section.

Rate filings shall include the information and data required under section 38a-479qqq if the policy is subject to said section, and an actuarial memorandum that includes, but is not limited to, pricing assumptions and claims experience, the requirements established in section 15 of this act, and premium rates and loss ratios from the inception of the policy.

Each premium rate filed on or after January 1, 2021, shall, if the insurer intends to account for rebates, as defined in section 38a-479ooo in the manner specified in section 38a-479rrr, account for such rebates in such manner, if the policy is subject to section 38a-479rrr.

The commissioner may adopt regulations, in accordance with the provisions of chapter 54, to establish a procedure for reviewing such policies.

The commissioner shall disapprove the use of such form at any time if it does not comply with the requirements of law, or if it contains a provision or provisions that are unfair or deceptive or that encourage misrepresentation of the policy.

The commissioner shall notify, in writing, the insurer that has filed any such form of the commissioner's disapproval, specifying the reasons for disapproval, and ordering that no such insurer shall deliver or issue for delivery to any person in this state a policy on or containing LCO 15 of 26 Substitute Bill No.

10 such form.

The provisions of section 38a-19 shall apply to such orders.

Asused in this subsection, "lossratio" means theratio ofincurredclaims to earned premiums by the number of years of policy duration for all combined durations.

(b) (1) No rate filed under the provisions of subsection (a) of this section shall be effective until it has been approved by the commissioner in accordance with regulations adopted pursuant to this subsection.

The commissioner shall adopt regulations, in accordance with the provisions of chapter 54, to prescribe standards to ensure that such rates shall not be excessive, inadequate, [or] unfairly discriminatory [.

The commissioner may disapprove such rate if it fails to comply with such standards, except that no rate filed under the provisions of subsection (a) of this section for any Medicare supplement policy shall be effective unless approved in accordance with section 38a-474] or unaffordable pursuant to the provisions of section 15 of this act.

(2) Any rate filed in accordance with the provisions of subsection (a) of this section for health insurance that provides coverage of the type specifiedinsubdivisions(1), (2),(4),(11)and(12)ofsection38a-469shall be approved in accordance with the provisions of section 15 of this act.

(c) (1) No rate filed in accordance with the provisions of subsection (a) of this section for any Medicare supplement policy shall be effective unless approved in accordance with the provisions of section 38a-474.

[(c)] (2) No insurance company, fraternal benefit society, hospital service corporation, medical service corporation, health care center or other entity that delivers or issues for delivery in this state any Medicare supplement policies or certificates shall incorporate in its rates or determinations to grant coverage for Medicare supplement insurance policies or certificates any factors or values based on the age, gender, previous claims history or the medical condition of any person covered by such policy or certificate.

Sec.

11.

Section 38a-513 of the general statutes is repealed and the following is substituted in lieu thereof (Effective January 1, 2026):

LCO 16 of 26 Substitute Bill No.

10 (a) [(1)] No group health insurance policy, as defined by the commissioner, or certificate shall be delivered or issued for delivery in this state unless a copy of the form for such policy or certificate has been submitted to and approved by the commissioner under the regulations adopted pursuant to this section.

(b)(2) (1) No rategroup filedhealth ininsurance accordancepolicy withor thecertificate provisionsfor ofa subsectionsmall (a)employer, ofas thisdefined in section 38a-564, shall be effectivedelivered untilor suchissued ratefor hasdelivery beenin approvedthis bystate unless the commissionerpremium inrates accordancehave withbeen regulationssubmitted adopted pursuant to thisand subsectionapproved orby asthe providedcommissioner. under subdivision (2) of this subsection.

TheIf commissioner shall adopt regulations, in accordance with the provisionscommissioner ofdetermines chapter 54, to prescribe standards to ensure that suchany ratessmall shallgroup nothealth beinsurance excessive,carrier's inadequate,average unfairlypremium discriminatoryrate orPublic unaffordableAct pursuantNo. to the provisions of section 15 of this act.

(2)25-94 Any10 rate filed in accordance with the provisions of subsection24 (a)Substitute ofSenate thisBill sectionNo. for a group health insurance policy that provides coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 shall be approved in accordance with the provisions of section 15 of this act.

[(2)]10 (c)increase, Noas groupapproved healthby insurancethe policycommissioner, or certificate for a small employer, asexceeded definedthe inhealth care cost growth benchmark established pursuant to section 38a-564,19a-754g shallfor beeach deliveredof orthe issuedtwo most recent plan years for deliverywhich insuch thishealth statecare unlesscost growth benchmark data is available, the commissioner may reduce such policy's or certificate's requested premium ratesrate havefiling beenunder submittedthe toprovisions LCOof 17subsection (a) of 26this Substitutesection Billby No.not more than two percentage points of such premium rate filed in addition to any other premium rate reductions authorized under this title.

10Premium andrate approvedfilings byshall include the commissionerinformation inand accordancedata withrequired under section 38a-479qqq if the provisionspolicy ofis sectionsubject 15to said section, and an actuarial memorandum that includes, but is not limited to, pricing assumptions and claims experience, and premium rates and loss ratios from the inception of thisthe act.policy.

PremiumEach premium rate filingsfiled shallon includeor theafter informationJanuary and1, data2021, requiredshall, under section 38a-479qqq if the policyinsurer isintends subject to saidaccount section,for andrebates, anas actuarialdefined memorandumin thatsection includes,38a-479ooo butin is not limited to, pricing assumptions and claims experience, the requirementsmanner setspecified forth in section 1538a- of479rrr, thisaccount act,for andsuch premiumrebates ratesin andsuch lossmanner, ratiosif from the inceptionpolicy ofis thesubject policy.to section 38a-479rrr.

Each premium rate filed on or after January 1, 2021, shall, if the insurer intends to account for rebates, as defined in section 38a-479ooo in the manner specified in section 38a-479rrr, account for such rebates in such manner, if the policy is subject to section 38a-479rrr.

[(b)] (d) No insurance company, fraternal benefit society, hospital service corporation, medical service corporation, health care center or other entity that delivers or issues for delivery in this state any Medicare supplement policies or certificates shall incorporate in its rates or determinations to grant coverage for Medicare supplement insurance policies or certificates any factors or values based on the age, gender, previous claims history or the medical condition of any person covered by such policy or certificate.

[(c)] (e) Nothing in this chapter shall preclude the issuance of a group health insurance policy that includes an optional life insurance rider, provided the optional life insurance rider shall be filed with and approved by the Insurance Commissioner pursuant to section 38a-430.

Anycompanyofferingsuchpoliciesforsaleinthisstateshallbelicensed to sell life insurance in this state pursuant to the provisions of section 38a-41.

[(d)] (f) Not later than January 1, 2009, the commissioner shall adopt regulations, in accordance with chapter 54, to establish minimum standards for benefits in group specified disease policies, certificates, riders, endorsements and benefits.

LCO 18 of 26 Substitute Bill No.

10 Sec.

12.

Subdivision (1) of subsection (a) of section 38a-183 of the general statutes is repealed and the following is substituted in lieu thereof (Effective January 1, 2026):

(a) (1) A health care center governed by sections 38a-175 to 38a-194, inclusive,shallnotenterintoanyagreementwithsubscribersunlessand until [it] such health care center has filed with the commissioner a full schedule of the amounts to be paid by the subscribers and has obtained thecommissioner'sapproval [thereof]inaccordance withtheprovisions of section 15 of this act.

Such filing shall include the information and data required under section 38a-479qqq if the contract or policy is subject to said section, and an actuarial memorandum that includes, but is not limited to, pricing assumptions and claims experience, and premium rates and loss ratios from the inception of the contract or policy.

The commissioner [may refuse such approval if the commissioner finds such amounts to] shall adopt regulations, in accordance with the provisions of chapter 54, to prescribe standards to ensure that such amounts shall not be excessive, inadequate, [or] discriminatory or unaffordable pursuant to the provisions of section 15 of this act.

As used in this subsection, "loss ratio" means the ratio of incurred claims to earned premiums by the number of years of policy duration for all combined durations.

13.8.

Subsection (a) of section 38a-208 of the general statutes is repealedandthefollowingissubstitutedinlieuthereof(EffectiveJanuary 1, 2026):

(a) No such corporation shall enter into any contract with subscribers unless and until it has filed with the Insurance Commissioner a full schedule of the rates to be paid by the subscribers and has obtained said commissioner's approval [thereof] in accordance with the provisions of section15 ofthisact.

Suchfiling shallinclude anactuarialmemorandum that includes, but is not limited to, pricing assumptions and claims experience, and premium rates and loss ratios from the inception of the contract.

The commissioner [may refuse such approval if the commissioner finds such rates to] shall adopt regulations, in accordance LCO 19 of 26 Substitute Bill No.

10 with the provisions of chapter 54, to prescribe standards to ensure that such amounts shall not be excessive, inadequate, [or] discriminatory or unaffordable pursuant to the provisions of section 15 of this act.

As used in this subsection, "loss ratio" means the ratio of incurred claims to earned premiums by the number of years of policy duration for all combined durations.

Sec.

14.

Subsection (a) of section 38a-218 of the general statutes is repealedandthefollowingissubstitutedinlieuthereof(EffectiveJanuary 1, 2026):

(a) No such medical service corporation shall enter into any contract with subscribers unless and until it has filed with the Insurance Commissioner a full schedule of the rates to be paid by the subscriber and has obtained said commissioner's approval [thereof] in accordance with the provisions of section 15 of this act.

Such filing shall include an actuarial memorandum that includes, but is not limited to, pricing assumptions and claims experience, and premium rates and loss ratios from the inception of the contract.

The commissioner [may refuse such approval if the commissioner finds such rates are] shall adopt regulations, inaccordance withtheprovisionsofchapter 54,to prescribe standards to ensure that such amounts shall not be excessive, inadequate, [or] discriminatory or unaffordable pursuant to the provisionsofsection15 ofthisact.As usedin thissubsection, "loss ratio" means the ratio of incurred claims to earned premiums by the number of years of policy duration for all combined durations.

Sec.

15.

(NEW) (Effective January 1, 2026) (a) (1) With respect to a health insurance policy, agreement or contract that provides coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 of the general statutes, any (A) rate filed for such policy pursuant to section 38a-481 of the general statutes, as amended by this act, (B) rate filed for such policy pursuant to section 38a-513 of the general statutes, as amended by this act, (C) schedule of amounts filed for such agreement pursuant to section 38a-183 of the general statutes, as amended by this act, (D) schedule of rates filed for such contract LCO 20 of 26 Substitute Bill No.

10 pursuant to section 38a-208 of the general statutes, as amended by this act, or (E) schedule of rates filed for such contract pursuant to section 38a-218 of the general statutes, as amended by this act, on or after January 1, 2026, shall be filed not later than one hundred twenty calendar days prior to the proposed effective date of such rates or amounts.

(2) Each filer making a rate or amount filing pursuant to this subsection shall, on the date such filer submits such rate or amount filing to the Insurance Commissioner, include with such filer's rate or amount filing an actuarial memorandum, certified by a qualified actuary, that to the best of such actuary's knowledge, (A) such rate or amount filing is in compliance with the laws of this state and federal law, as applicable, and (B) the rate or amount filing is not excessive, as described in subdivision (1) of subsection (c) of this section.

For the purposes of this subparagraph, "qualified actuary" means a member in good standing of the American Academy of Actuaries who is qualified in accordance with the standards of the American Academy of Actuaries.

(3) (A) Notwithstanding the provisions of section 38a-69a of the general statutes, the Insurance Department shall post on the department's Internet web site all documents, materials and other information provided to or requested by the department in relation to any such rate or amount filing made pursuant to this subsection, including, but not limited to, financial reports, financial statements, actuarial reports and actuarial memoranda.

Such rate or amount filing and such documents, materials and other information shall be posted on such web site not later than three business days after the department receives such filing, and such posting shall be updated to include any correspondence between the department and such filer.

(B) The department shall provide for a written public comment periodofnotlessthanthirty calendardaysfollowing thepostingofsuch filing.

The department shall include in such posting the date such public comment period closes and instructions for the public to submit LCO 21 of 26 Substitute Bill No.

10 comments to the department.

(b) (1) The commissioner shall hold a public hearing for each rate or amount filed under the provisions of subdivision (1) of subsection (a) of this section.

Not later than five business days after the posting of such rate or amount filing on the department's Internet web site in accordance with the provisions of subparagraph (A) of subdivision (3) of subsection (a) of this section, the commissioner shall set a public hearing date for such rate or amount filing and shall post the date, place and time of such public hearing in a conspicuous place on the department's Internet web site.

(2) Such public hearing shall be (A) held after the end of the public comment period specified in subparagraph (B) of subdivision (3) of subsection (a) of this section, but not later than prior to the proposed effective date of such rate or amount, at a place and time that is convenient to the public, and (B) conducted in accordance with the provisions of chapter 54 of the general statutes, this section and section 16 of this act.

(3) Upon setting the date, place and time of the public hearing for such rate or amount filing, the commissioner shall immediately notify the filer of such rate or amount filing of the date, place and time of the public hearing.

(c) The commissioner shall not approve a rate or amount filing submitted in accordance with the provisions of this section if such rate or amount filing is excessive, inadequate, unfairly discriminatory or unaffordable.

The commissioner shall conduct an actuarial review to determine if the methodology and assumptions used to develop such rate or amount filing are actuarially sound and in compliance with the ActuarialStandardsofPracticeissuedbytheActuarialStandardsBoard.

(1) Any rate or amount shall be considered excessive if it is unreasonably high for the insurance provided in relation to the underlying risks and costs after due consideration of:

(A) The experience of such filer;

(B) such filer's past and projected costs, LCO 22 of 26 Substitute Bill No.

10 including amounts to be paid for commissions;

(C) any transfers of funds to the holding or parent company, subsidiary or affiliate of such filer;

(D) such filer's rate of return on assets or profitability, as compared to similar filers;

(E) a reasonable margin for profit and contingencies;

(F) any public comments received on such filing in accordance with the provisions of subparagraph (B) of subdivision (3) of subsection (a) of this section;

and (G) other factors the commissioner deems relevant.

(2) Any rate or amount shall be considered inadequate if such rate or amount is unreasonably low for the insurance provided in relation to the underlying risks and costs and continued use of such rate or amount would endanger solvency of such filer.

(3) Any rate or amount shall be considered unfairly discriminatory if the premium charged for any classification is not reasonably related to the underlying risks and costs, such that different premiums result for insureds with similar risks and costs.

(4) Any rate or amount shall be considered unaffordable if the commissioner determines such rate or amount is inconsistent with the inflation-adjusted Connecticut Health Affordability Index commissioned by the Office of Health Strategy and the Office of the State Comptroller, or another metric jointly designated by the commissioner and the Commissioner of Health Strategy.

(d) Not later than thirty days after such public hearing held in accordance with the provisions of subsection (b) of this section, the commissioner shall issue a written decision approving, disapproving or modifying such rate or amount filing.

Such decision shall specify all factors used to reach such decision and shall be posted on the department's Internet web site not later than two business days after the commissioner issues such decision.

Sec.

16.

(NEW) (Effective January 1, 2026) (a) Notwithstanding sections 4-176 and 4-177a of the general statutes, the Healthcare Advocate or the Attorney General, or both, may be parties to any public hearing held in accordance with the provisions of section 15 of this act.

LCO 23 of 26 Substitute Bill No.

10 (b) Subject to the provisions of section 4-181 of the general statutes, (1) the Healthcare Advocate or the Attorney General, or both, shall have access to the records of the Insurance Department regarding any rate or amount filing made in accordance with the provisions of section 15 of this act, and (2) attorneys, actuaries, accountants and other experts who are part of the Insurance Commissioner's staff and who review or assist in the determination of such filing pursuant to the provisions of section 15 of this act shall cooperate with the Healthcare Advocate or Attorney General, or both, to carry out the provisions of this section.

(c) The Healthcare Advocate or the Attorney General, or both, may (1) summon and examine under oath such witnesses as the Healthcare Advocate or the Attorney General deems necessary for the review of a rate or amount filing made in accordance with the provisions of section 15 of this act, and (2) require the filer or any holding or parent company or subsidiary of such filer to produce books, vouchers, memoranda, papers, letters, contracts and other documents, regardless of the format in which such materials are stored.

Any such books, vouchers, memoranda, papers, letters, contracts or other documents shall be limited to such information or transactions between such filer and the holding or parent company or subsidiary that are reasonably related to the subject matter of the filing.

Sec.

17.

and (2) "Medical"Medically necessity"necessary" has the same meaning as provided in section 38a-482a of the general statutes.

(b) No individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 ofthegeneralstatutesdelivered,issuedfor delivery,renewed,amended or continued in this state on or after January 1, 2026, shallshall, (1) if such policy providescoverageprovides coverage for generalanesthesia,(A)general anesthesia, (1) impose an arbitrary time limit on reimbursement for general anesthesia provided during LCOany 24Public ofAct 26 Substitute Bill No.

1025-94 any11 medicallyof necessary24 procedure,Substitute orSenate (B)Bill deny,No. reduce, terminate or fail to provide such reimbursement, in whole or in part, for general anesthesiasolelybecausethedurationofcareexceededapredetermined time limit as determined by the insurer, or (2) impose unilateral arbitrary limitations on reimbursement for medically necessary ancillary services.

(c)10 Themedically medicalnecessitynecessary forprocedure, administeringor generalanesthesiaduring(2) anydeny, medicalreduce, procedureterminate shallor befail determinedto byprovide such reimbursement, in whole or in part, for general anesthesia solely because the attendingduration board-of certifiedcare anesthesiologistexceeded duringa suchpredetermined medicaltime procedure.limit as determined by the insurer.

18.9.

and (2) "Medical"Medically necessity"necessary" has the same meaning as provided in section 38a-482a of the general statutes.

(b) No group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 of the general statutes delivered, issued for delivery, renewed, amended or continued in this state on or after January 1, 2026, shallshall, (1) if such policy providescoverageprovides coverage for generalanesthesia,(A)general anesthesia, (1) impose an arbitrary time limit on reimbursement for general anesthesia provided during any medically necessary procedure, or (B)(2) deny, reduce, terminate or fail to provide such reimbursement, in whole or in part, for general anesthesiasolelybecausethedurationofcareexceededapredeterminedanesthesia timesolely limitbecause as determined by the insurer,duration orof (2)care imposeexceeded unilaterala arbitrarypredetermined limitationstime onlimit reimbursementas fordetermined medicallyby necessarythe ancillaryinsurer. services.

(c)Sec. The medicalnecessity for administering generalanesthesiaduring any medical procedure shall be determined by the attending board- certified anesthesiologist during such medical procedure.

LCO10. 25 of 26 Substitute Bill No.

10Section This19a-508c actof shallthe takegeneral effectstatutes asis followsrepealed and shall amend the following sections:is substituted in lieu thereof (Effective January 1, 2026):

Section(a) 1As Octoberused 1,in 2025this Newsection: section Sec.

2(1) October"Affiliated 1,provider" 2025means 38a-477ee(c)a Sec.provider that is:

3(A) fromEmployed passageby Newa hospital or health system, (B) under a professional services agreement with a hospital or health system that permits such hospital or health systemtobillonbehalfofsuchprovider,or(C)aclinicalfacultymember of a medical school, as defined in section Sec.33-182aa, that is affiliated with a hospital or health system in a manner that permits such hospital or Public Act No.

425-94 October12 1,of 202524 NewSubstitute sectionSenate Sec.Bill No.

510 Januaryhealth 1,system 2026to 38a-591c(a)bill andon (b)behalf Sec.of such clinical faculty member;

6(2) January"Campus" 1,means: 2026 38a-591e(c) Sec.

7(A) JanuaryThe 1,physical 2026area 38a-510immediately Sec.adjacent to a hospital's main buildings and other areas and structures that are not strictly contiguous to the main buildings but are located within two hundred fifty yards of the main buildings, or (B) any other area that has beendeterminedonanindividualcasebasisbytheCentersforMedicare and Medicaid Services to be part of a hospital's campus;

8(3) January"Facility 1,fee" 2026means 38a-544any Sec.fee charged or billed by a hospital or health system for outpatient services provided in a hospital-based facility that is:

9(A) JulyIntended 1,to 2026compensate Newthe sectionhospital Sec.or health system for the operational expenses of the hospital or health system, and (B) separate and distinct from a professional fee;

10(4) January"Health 1,care 2026provider" 38a-481(a)means toan (c)individual, Sec.entity, corporation, person or organization, whether for-profit or nonprofit, that furnishes, bills or is paid for health care service delivery in the normal course of business, including, but not limited to, a health system, a hospital, a hospital-based facility, a freestanding emergency department and an urgent care center;

11(5) January"Health 1,system" 2026means: 38a-513 Sec.

12(A) JanuaryA 1,parent 2026corporation 38a-183(a)(1)of Sec.one or more hospitals and any entity affiliated with such parent corporation through ownership, governance, membership or other means, or (B) a hospital and any entity affiliated with such hospital through ownership, governance, membership or other means;

13(6) January"Hospital" 1,has 2026the 38a-208(a)same Sec.meaning as provided in section 19a-490;

14(7) January"Hospital-based 1,facility" 2026means 38a-218(a)a Sec.facility that is owned or operated, in whole or in part, by a hospital or health system where hospital or professional medical services are provided;

15(8) January"Medicaid" 1,means 2026the Newprogram sectionoperated Sec.by the Department of Public Act No.

1625-94 January13 1,of 202624 NewSubstitute sectionSenate Sec.Bill No.

1710 JanuarySocial 1,Services 2026pursuant Newto section Sec.17b-260 and authorized by Title XIX of the Social Security Act, as amended from time to time;

18(9) January"Observation" 1,means 2026services Newfurnished sectionby INSa Jointhospital Favorableon Subst.the hospital's campus, regardless of length of stay, including use of a bed and periodic monitoring by the hospital's nursing or other staff to evaluate an outpatient's condition or determine the need for admission to the hospital as an inpatient;

JUD(10) Joint"Payer Favorablemix" APPmeans Jointthe Favorableproportion LCOof 26different sources of 26payment received by a hospital or health system, including, but not limited to, Medicare, Medicaid, other government-provided insurance, private insurance and self-pay patients;

(11) "Professional fee" means any fee charged or billed by a provider for professional medical services provided in a hospital-based facility;

(12) "Provider" means an individual, entity, corporation or health care provider, whether for profit or nonprofit, whose primary purpose is to provide professional medical services;

and (13) "Tagline" means a short statement written in a non-English language that indicates the availability of language assistance services free of charge.

(b) If a hospital or health system charges a facility fee utilizing a current procedural terminology evaluation and management (CPT E/M) code or assessment and management (CPT A/M) code for outpatient services provided at a hospital-based facility where a professional fee is also expected to be charged, the hospital or health system shall provide the patient with a written notice that includes the following information:

(1) That the hospital-based facility is part of a hospital or health system and that the hospital or health system charges a facility fee that Public Act No.

25-94 14 of 24 Substitute Senate Bill No.

10 is in addition to and separate from the professional fee charged by the provider;

(2) (A) The amount of the patient's potential financial liability, including any facility fee likely to be charged, and, where professional medicalservicesareprovidedbyanaffiliatedprovider, anyprofessional fee likely to be charged, or, if the exact type and extent of the professional medical services needed are not known or the terms of a patient's health insurance coverage are not known with reasonable certainty, an estimate of the patient's financial liability based on typical or average charges for visits to the hospital-based facility, including the facility fee, (B) a statement that the patient's actual financial liability will depend on the professional medical services actually provided to the patient, (C) an explanation that the patient may incur financial liability that is greater than the patient would incur if the professional medical services were not provided by a hospital-based facility, and (D) a telephone number the patient may call for additional information regarding such patient's potential financial liability, including an estimate of the facility fee likely to be charged based on the scheduled professional medical services;

and (3) That a patient covered by a health insurance policy should contact the health insurer for additional information regarding the hospital's or health system's charges and fees, including the patient's potential financial liability, if any, for such charges and fees.

(c) If a hospital or health system charges a facility fee without utilizing a current procedural terminology evaluation and management (CPT E/M) code for outpatient services provided at a hospital-based facility, located outside the hospital campus, the hospital or health system shall provide the patient with a written notice that includes the following information:

(1) That the hospital-based facility is part of a hospital or health Public Act No.

25-94 15 of 24 Substitute Senate Bill No.

10 system and that the hospital or health system charges a facility fee that may be in addition to and separate from the professional fee charged by a provider;

(2) (A) A statement that the patient's actual financial liability will depend on the professional medical services actually provided to the patient, (B) an explanation that the patient may incur financial liability that is greater than the patient would incur if the hospital-based facility wasnot hospital-based, and(C)atelephone number thepatient maycall for additional information regarding such patient's potential financial liability, including an estimate of the facility fee likely to be charged based on the scheduled professional medical services;

and (3) That a patient covered by a health insurance policy should contact the health insurer for additional information regarding the hospital's or health system's charges and fees, including the patient's potential financial liability, if any, for such charges and fees.

(d) Each initial billing statement that includes a facility fee shall:

(1) Clearly identify the fee as a facility fee that is billed in addition to, or separately from, any professional fee billed by the provider;

(2) provide thecorresponding Medicare facility fee reimbursement rate for thesame service asa comparisonor,ifthere isno corresponding Medicare facility fee for such service, (A) the approximate amount Medicare would have paid the hospital for the facility fee on the billing statement, or (B) the percentage of the hospital's charges that Medicare would have paid the hospital for the facility fee;

(3) include a statement that the facility fee is intended to cover the hospital's or health system's operational expenses;

(4) inform the patient that the patient's financial liability may have been less if the services had been provided at a facility not owned or operated by the hospital or health system;

and (5) include written notice of the patient's right to request a reduction in the facility fee or any other portion of the bill and a telephone number that the patient may use to request such a reduction without regard to whether such patient Public Act No.

25-94 16 of 24 Substitute Senate Bill No.

10 qualifies for, or is likely to be granted, any reduction.

Not later than October 15, 2022, and annually thereafter, each hospital, health system and hospital-based facility shall submit to the Health Systems Planning Unit of the Office of Health Strategy a sample of a billing statement issued by such hospital, health system or hospital-based facility that complies with the provisions of this subsection and which represents the format of billing statements received by patients.

Such billing statement shall not contain patient identifying information.

(e) The written notice described in subsections (b) to (d), inclusive, and (h) to (j), inclusive, of this section shall be in plain language and in a form that may be reasonably understood by a patient who does not possess special knowledge regarding hospital or health system facility fee charges.

On and after October 1, 2022, such notices shall include tag lines in at least the top fifteen languages spoken in the state indicating that the notice is available in each of those top fifteen languages.

The fifteen languages shall be either the languages in the list published by the Department of Health and Human Services in connection with section 1557 of the Patient Protection and Affordable Care Act, P.L.

111- 148, or, as determined by the hospital or health system, the top fifteen languages in the geographic area of the hospital-based facility.

(f) (1) For nonemergency care, if a patient's appointment is scheduled to occur ten or more days after the appointment is made, such written notice shall be sent to the patient by first class mail, encrypted electronic mail or a secure patient Internet portal not less than three days after the appointment is made.

If an appointment is scheduled to occur less than ten days after the appointment is made or if the patient arrives without anappointment, suchnotice shallbehand-deliveredtothepatient when the patient arrives at the hospital-based facility.

(2) For emergency care, such written notice shall be provided to the patient as soon as practicable after the patient is stabilized in accordance with the federal Emergency Medical Treatment and Active Labor Act, Public Act No.

25-94 17 of 24 Substitute Senate Bill No.

10 USC 1395dd, as amended from time to time, or is determined not to have an emergency medical condition and before the patient leaves the hospital-based facility.

If the patient is unconscious, under great duress or for any other reason unable to read the notice and understand and act on his or her rights, the notice shall be provided to the patient's representative as soon as practicable.

(g) Subsections (b) to (f), inclusive, and (l) of this section shall not apply if a patient is insured by Medicare or Medicaid or is receiving services under a workers' compensation plan established to provide medical services pursuant to chapter 568.

(h) A hospital-based facility shall prominently display written notice in locations that are readily accessible to and visible by patients, including patient waiting or appointment check-in areas, stating:

(1) That the hospital-based facility is part of a hospital or health system, (2) the name of the hospital or health system, and (3) that if the hospital- based facility charges a facility fee, the patient may incur a financial liability greater than the patient would incur if the hospital-based facility was not hospital-based.

On and after October 1, 2022, such notices shall include tag lines in at least thetop fifteen languages spoken in the state indicating that the notice is available in each of those top fifteen languages.

The fifteen languages shall be either the languages in the list published by the Department of Health and Human Services in connection with section 1557 of the Patient Protection and Affordable Care Act, P.L.

111-148, or, as determined by the hospital or health system, the top fifteen languages in the geographic area of the hospital- based facility.

Not later than October 1, 2022, and annually thereafter, each hospital-based facility shall submit a copy of the written notice required by this subsection to the Health Systems Planning Unit of the Office of Health Strategy.

(i) A hospital-based facility shall clearly hold itself out to the public and payers as being hospital-based, including, at a minimum, by stating Public Act No.

25-94 18 of 24 Substitute Senate Bill No.

10 the name of the hospital or health system in its signage, marketing materials, Internet web sites and stationery.

(j) A hospital-based facility shall, when scheduling services for which a facility fee may be charged, inform the patient (1) that the hospital- based facility is part of a hospital or health system, (2) of the name of the hospital or health system, (3) that the hospital or health system may charge a facility fee in addition to and separate from the professional fee charged by the provider, and (4) of the telephone number the patient may call for additional information regarding such patient's potential financial liability.

(k) (1) If any transaction described in subsection (c) of section 19a- 486i results in the establishment of a hospital-based facility at which facility fees may be billed, the hospital or health system, that is the purchaser in such transaction shall, not later than thirty days after such transaction, provide written notice, by first class mail, of the transaction to each patient served within the three years preceding the date of the transaction by the health care facility that has been purchased as part of such transaction.

(2) Such notice shall include the following information:

(A) A statement that the health care facility is now a hospital-based facility andis part ofa hospitalor healthsystem,thehealthcare facility's full legal and business name and the date of such facility's acquisition by a hospital or health system;

(B) The name, business address and phone number of the hospital or health system that is the purchaser of the health care facility;

(C)A statement that thehospital-based facility bills, or is likely to bill, patients a facility fee that may be in addition to, and separate from, any professional fee billed by a health care provider at the hospital-based facility;

Public Act No.

25-94 19 of 24 Substitute Senate Bill No.

10 (D) (i) A statement that the patient's actual financial liability will depend on the professional medical services actually provided to the patient, and (ii) an explanation that the patient may incur financial liability that is greater than the patient would incur if the hospital-based facility were not a hospital-based facility;

(E) The estimated amount or range of amounts the hospital-based facility may bill for a facility fee or an example of the average facility fee billed at such hospital-based facility for the most common services provided at such hospital-based facility;

and (F) A statement that, prior to seeking services at such hospital-based facility, a patient covered by a health insurance policy should contact the patient's health insurer for additional information regarding the hospital-based facility fees, including the patient's potential financial liability, if any, for such fees.

(3) A copy of the written notice provided to patients in accordance with this subsection shall be filed with the Health Systems Planning Unit of the Office of Health Strategy, established under section 19a-612.

Said unit shall post a link to such notice on its Internet web site.

(4)Ahospital,healthsystemorhospital-basedfacilityshallnotcollect a facility fee for services provided at a hospital-based facility that is subject to the provisions of this subsection from the date of the transaction until at least thirty days after the written notice required pursuant to this subsection is mailed to the patient or a copy of such notice is filed with the Health Systems Planning Unit of the Office of Health Strategy, whichever is later.

A violation of this subsection shall be considered an unfair trade practice pursuant to section 42-110b.

(5) Not later than July 1, 2023, and annually thereafter, each hospital- based facility that was the subject of a transaction, as described in subsection (c) of section 19a-486i, during the preceding calendar year Public Act No.

25-94 20 of 24 Substitute Senate Bill No.

10 shall report to the Health Systems Planning Unit of the Office of Health Strategy the number of patients served by such hospital-based facility in the preceding three years.

(l) (1) Notwithstanding the provisions of this section, no hospital, health system or hospital-based facility shall collect a facility fee for (A) outpatient health care services that use a current procedural terminology evaluation and management (CPT E/M) code or assessment and management (CPT A/M) code and are provided at a hospital-based facility located off-site from a hospital campus, or (B) outpatient health care services provided at a hospital-based facility located off-site from a hospital campus received by a patient who is uninsured of more than the Medicare rate.

(2) Notwithstanding the provisions of this section, on and after July 1, 2024, no hospital or health system shall collect a facility fee for outpatient health care services that use a current procedural terminology evaluation and management (CPT E/M) code or assessment and management (CPT A/M) code and are provided on the hospital campus.

The provisions of this subdivision shall not apply to (A) an emergency department located on a hospital campus, or (B) observation stays on a hospital campus and (CPT E/M) and (CPT A/M) codes when billed for the following services:

(i) Wound care, (ii) orthopedics, (iii) anticoagulation, (iv) oncology, (v) obstetrics, and (vi) solid organ transplant.

(3) Notwithstanding the provisions of subdivisions (1) and (2) of this subsection, in circumstances when an insurance contract that is in effect on July 1, 2016, provides reimbursement for facility fees prohibited under the provisions of subdivision (1) of this subsection, and in circumstances when an insurance contract that is in effect on July 1, 2024, provides reimbursement for facility fees prohibited under the provisions of subdivision (2) of this subsection, a hospital or health system may continue to collect reimbursement from the health insurer Public Act No.

25-94 21 of 24 Substitute Senate Bill No.

10 for such facility fees until the applicable date of expiration, renewal or amendment of such contract, whichever such date is the earliest.

(4) The provisions of this subsection shall not apply to a freestanding emergency department.

As used in this subdivision, "freestanding emergency department" means a freestanding facility that (A) is structurally separate and distinct from a hospital, (B) provides emergency care, (C) is a department of a hospital licensed under chapter 368v, and (D) has been issued a certificate of need to operate as a freestanding emergency department pursuant to chapter 368z.

(5) (A) On and after July 1, 2024, if the Commissioner of Health Strategy receives information and has a reasonable belief, after evaluating such information, that any hospital, health system or hospital-based facility charged facility fees, other than through isolated clerical or electronic billing errors, in violation of any provision of this section, or rule or regulation adopted thereunder, such hospital, health system or hospital-based facility shall be subject to a civil penalty of up to one thousand dollars.

The commissioner may issue a notice of violation and civil penalty by first class mail or personal service.

Such notice shall include:

(i) A reference to the section of the general statutes, rule or section of the regulations of Connecticut state agencies believed or alleged to have been violated;

(ii) a short and plain language statement of the matters asserted or charged;

(iii) a description of the activity to cease;

(iv) a statement of the amount of the civil penalty or penalties that may be imposed;

(v) a statement concerning the right to a hearing;

and (vi) a statement that such hospital, health system or hospital-based facility may, not later than tenbusiness days after receipt of such notice, make a request for a hearing on the matters asserted.

(B) The hospital, health system or hospital-based facility to whom such notice is provided pursuant to subparagraph (A) of this subdivision may, not later than ten business days after receipt of such notice, make written application to the Office of Health Strategy to Public Act No.

25-94 22 of 24 Substitute Senate Bill No.

10 request a hearing to demonstrate that such violation did not occur.

The failure to make a timely request for a hearing shall result in the issuance of a cease and desist order or civil penalty.

All hearings held under this subsection shall be conducted in accordance with the provisions of chapter 54.

(C) Following any hearing before the Office of Health Strategy pursuant to this subdivision, if said office finds, by a preponderance of the evidence, that such hospital, health system or hospital-based facility violated or is violating any provision of this subsection, any rule or regulation adopted thereunder or any order issued by said office, said office shall issue a final cease and desist order in addition to any civil penalty said office imposes.

(6) A violation of this subsection shall be considered an unfair trade practice pursuant to section 42-110b.

(m) (1) Each hospital and health system shall report not later than October 1, 2023, and thereafter not later than July 1, 2024, and annually thereafter, totheCommissioner ofHealthStrategy,onaformprescribed by the commissioner, concerning facility fees charged or billed during the preceding calendar year.

Such report shall include, but need not be limited to, (A) the name and address of each facility owned or operated by the hospital or health system that provides services for which a facility fee is charged or billed, and an indication as to whether each facility is located on or outside of the hospital or health system campus, (B) the number of patient visits at each such facility for which a facility fee was charged or billed, (C) the number, total amount and range of allowable facility fees paid at each such facility disaggregated by payer mix, (D) for each facility, the total amount of facility fees charged and the total amount of revenue received by the hospital or health system derived from facility fees, (E) the total amount of facility fees charged and the total amount of revenue received by the hospital or health system from all facilities derived from facility fees, (F) a description of Public Act No.

25-94 23 of 24 Substitute Senate Bill No.

10 the ten procedures or services that generated the greatest amount of facility fee gross revenue, disaggregated by current procedural terminology (CPT) category [(CPT)] code for each such procedure or service and, for each such procedure or service, patient volume and the total amount of gross and net revenue received by the hospital or health system derived from facility fees, disaggregated by on-campus and off- campus, and (G) the top ten procedures or services for which facility fees are charged based on patient volume and the gross and net revenue received by the hospital or health system for each such procedure or service, disaggregated by on-campus and off-campus.

For purposes of this subsection, "facility" means a hospital-based facility that is located on a hospital campus or outside a hospital campus.

(2) The commissioner shall publish the information reported pursuant to subdivision (1) of this subsection, or post a link to such information, on the Internet web site of the Office of Health Strategy.

Governor's Action:

Approved June 24, 2025 Public Act No.

25-94 24 of 24