HB 7039 — AN ACT CONCERNING THE RETURN OF HEALTH CARE PROVIDER PAYMENTS, ESTABLISHING A WORKING GROUP TO STUDY PHARMACIST COMPENSATION FOR ADMINISTERING CERTAIN SERVICES, REVISING THE DEFINITION OF CLINICAL PEER AND CONCERNING THE CONNECTICUT UNFAIR INSURANCE PRACTICES ACT.

sHB7039 / File No.

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363 (d) The administrative staff of the joint standing committee of the General Assembly having cognizance of matters relating to insurance shall serve as administrative staff of the working group.

(e) Not later than February 1, 2026, the working group shall submit a report on its findings and legislative recommendations to the joint standing committee of General Assembly having cognizance of matters relating to insurance, in accordance with the provisions of section 11-4a of the general statutes.

The working group shall terminate on the date the working group submits such report or February 1, 2026, whichever is later.

(NEW) (Effective from passage) The Insurance Commissioner shall conduct a study of dental provider reimbursement rate practices for dental policies delivered, issued for delivery, renewed, amended or continued in this state for inpatient and outpatient dental services, including, but not limited to, an assessment of such practices in other states that provide dental providers with increased flexibility to negotiate reimbursement rates with health carriers.

Not later than February 1, 2026, the Insurance Commissioner shall report, in accordance with the provisions of section 11-4a of the general statutes, to the joint standing committee of the General Assembly having cognizance of matters relating to insurance on the findings of such study.

Sec.

4.

(NEW) (Effective January 1, 2026) Each individual 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, shall provide coverage for medical foods for individuals diagnosed with phenylketonuria.

For purposes of this section, "phenylketonuria" means an inherited amino LCO No.

5024 2 of 6 Raised Bill No.7039 acid disorder caused by a change in the phenylalanine hydroxylase gene.

Sec.

5.

(NEW) (Effective January 1, 2026) Each 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, shall provide coverage for medical foods for individuals diagnosed with phenylketonuria.

For purposes of this section, "phenylketonuria" means an inherited amino acid disorder caused by a change in the phenylalanine hydroxylase gene.

Sec.

6.

(NEW) (Effective January 1, 2026) Each individual 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, shall:

(1) Provide coverage for (A) motorized wheelchairs, including, but not limited to, used motorized wheelchairs requested by insureds, (B) repairs to motorized wheelchairs, and (C) replacement batteries for motorized wheelchairs;

and (2) establish centralized locations for each health carrier providing such coverage pursuant to the provisions of this section to collect such used motorized wheelchairs to be made available to such insureds.

Sec.

7.

(NEW) (Effective January 1, 2026) Each 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, shall:

(1) Provide coverage for (A) motorized wheelchairs, including, but not limited to, used motorized wheelchairs requested by insureds, (B) repairs to motorized wheelchairs, and (C) replacement batteries for motorized wheelchairs;

and (2) establish centralized locations for each health carrier providing such coverage pursuant to the provisions of this section to collect such used motorized wheelchairs to be made available to such insureds.

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7039 Sec.

8.

(NEW) (Effective October 1, 2025) No insurer, health care center, fraternal benefit society, hospital service corporation or medical service corporation or other entity delivering, issuing for delivery, renewing, amending or continuing an individual or group health insurance policy in this state on or after January 1, 2026, providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 of the general statutes, shall recover through health insurance premiums charged to policyholders any direct or indirect cost associated with such insurer's, center's, society's, corporation's or other entity's lobbying or legislative action, as such terms are defined insection 1-91 of thegeneral statutes.

Sec.

9.

(Effective from passage) (a) The Insurance Commissioner, in consultation with the Commissioner of Public Health, the Commissioner of Consumer Protection and the Commission of Pharmacy, shall conduct a study of compensation practices for health care servicesprovidedby pharmacists,including,but not limitedto, any vaccine administration, HIV-related tests, influenza-related tests and the prescribing of contraceptive devices or products approved by the federal Food and Drug Administration.

(b) Not later thanFebruary 1, 2026, theInsurance Commissioner shall report, in accordance with the provisions of section 11-4a of the general statutes, to the joint standing committees of the General Assembly having cognizance of matters relating to insurance and public health on the findings of such study and any recommendations concerning compensation to pharmacists.

For the purposes of this section, (1) "HIV- related test" and "influenza-related test" have the same meanings as provided in section 20-633f of the general statutes, and (2) "pharmacist" has the same meaning as provided in section 20-571 of the general statutes.

Sec.

10.

LCO(7) No."Clinical peer" means a physician or other health care professional who:

5024 4 of 6 Raised Bill No.7039 (7) "Clinical peer" means a physician or other health care professional who:

(i) 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 degreesHB7039 with/ trainingFile andNo. clinical experience in the treatment of child and adolescent substance use disorder or child and adolescent mental disorder, as applicable;

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363 degree with training and clinical experience in the treatment of child and adolescent substance use disorder or child and adolescent mental disorder, as applicable;

Sec.

4.

Section 38a-816 of the general statutes is amended by adding subdivisions (27) to (30), inclusive, as follows (Effective October 1, 2025):

(NEW) (27) (A) Where any health insurer or other entity responsible for providing payment to a health care provider pursuant to a contract between such health insurer or other entity and such health care provider maintains a health benefit plan incorporating certain health care providers as participating providers, failure of any such health insurer or other entity to make decisions in good faith based on the composition of the network of such participating providers, including, but not limited to, acceptance or denial of health care providers as participating providers.

No such decision by such health insurer or other entity shall be based solely on any potential financial impact to such health insurer or other entity;

(B) Failure by any health insurer or other entity to provide written notice to any participating provider and any such designated representative of such participating provider, as applicable, of any decision by such health insurer or other entity that impacts such participating provider's status as a participating provider of such health insurer or other entity.

Such notice shall provide an explanation of such decision by such health insurer or other entity;

and (C) Where any health insurer or other entity responsible for providing payment to a participating provider pursuant to a contract between such health insurer or other entity and such participating provider has reason to believe that such participating provider sHB7039 / File No.

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363 misunderstands such participating provider's in-network or out-of- network status, failure to promptly resolve such misunderstanding.

(NEW) (28) (A) Where any health insurer or other entity responsible forprovidingpaymenttoaparticipatingproviderpursuanttoacontract between such health insurer or other entity and such participating provider has reason to believe that such participating provider has a designated representative or contracting agent, failure of such health insurer or other entity to provide to such designated representative or contracting agent of such participating provider any communication relating to such participating provider's status as a participating provider with such health insurer or other entity;

and (B) Attempting to circumvent, disrupt, undermine or otherwise interfere with the relationship between any participating provider and such participating provider's designated representative or contracting agent.

(NEW) (29) Where any health insurer or other entity responsible for providing payment to a participating provider pursuant to a contract between such health insurer or other entity and such participating provider has a written agreement or fee schedule in place with such participating provider or network of participating providers, failure to adhere to the provisions of such written agreement or fee schedule, or any attempt by such health insurer or other entity to circumvent or misrepresent suchprovisionsofsuchwrittenagreementor feeschedule.

(NEW) (30) Any violation of section 38a-472f, as amended by this act.

Sec.

5.

Subparagraph (F) of subdivision (1) of subsection (e) of section 38a-472f of the general statutes is repealed and the following is substituted in lieu thereof (Effective October 1, 2025):

(F) Timely notify a health care provider or facility, when such health carrier has (i) included such health care provider or facility as a participating provider for any of such health carrier's health benefit plans, [of such health care provider's or facility's network participation sHB7039 / File No.

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363 status] (ii) denied such health care provider's or facility's request to be a participating provider for any of such health carrier's health benefit plans, or (iii) made any other change to such health care provider's or facility'sstatusasaparticipatingproviderforanyofsuchhealthcarrier's health benefit plans.

Any such notification by such health carrier pursuant to clause (ii) or (iii) of this subparagraph shall be in writing and provide an explanation of such denial or other such change to such health care provider'sor facility'sstatusasa participating provider.

Any decision made by a health carrier pursuant to the provisions of this subparagraph shall be made in good faith and shall not be based solely on any potential financial impact to such health carrier;

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6363 JanuaryThe 1,following 2026Fiscal NewImpact sectionStatement Sec.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.

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(1)The Prohibitbill: health carriers from retroactively denying or recouping payment of health insurance claims paid to health care providers for mental health and substance use disorder benefits after two years from the date of service and when such health carrier fails to provide notice to such health care provider;

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(7)sHB7039 require/ theFile InsuranceNo. Commissioner to study certain compensation practices for health care services provided by pharmacistslicensedinthisstate;and(8)revisethedefinitionof"clinical peer" with respect to utilization review of health care services and treatment.

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Proposed363 additionsOLR areBill indicatedAnalysis bysHB underline,7039 exceptAN thatACT whenCONCERNING theTHE entireRETURN textOF ofHEALTH aCARE billPROVIDER orPAYMENTS, resolutionESTABLISHING orA aWORKING sectionGROUP ofTO aSTUDY billPHARMACIST orCOMPENSATION resolutionFOR isADMINISTERING new,CERTAIN itSERVICES, isREVISING notTHE underlined.]DEFINITION LCOOF No.CLINICAL PEER AND CONCERNING THE CONNECTICUT UNFAIR INSURANCE PRACTICES ACT.

5024SUMMARY 6This ofbill 6makes several changes to health insurance statutes.

Principally, it does the following:

1.

shortens, from 18 to 12 months, the time period during which contracting organizations (e.g., insurers, HMOs, and preferred provider networks) may cancel, deny, or demand the return of payment from a health care provider for an authorized covered service due to an administrative or eligibility error, and requires the organization to have an electronic appeal process in place;

2.

for purposes of insurance adverse determination reviews, generally allows someone to serve as a clinical peer if he or she has substantial experience or expertise as a health care professional typically managing the condition under review;

and 3.

makes a health carrier’s (a) violation of network adequacy requirements or (b) specified actions toward health care providers participating in the carrier’s provider network (e.g., not acting in good faith when making network decisions and not adhering to a written agreement’s provisions) punishable as unfair insurance practices.

Lastly, the bill requires the Insurance and Real Estate Committee’s chairpersons, or their designees, to convene an 11-member working sHB7039 / File No.

363 10 sHB7039 File No.

363 group by July 1, 2025, to study compensating pharmacists who provide health care services (e.g., HIV and influenza testing, administering vaccines, and prescribing contraception).

The group must report its findingsand legislative recommendationsto thecommittee by February 1, 2026.

EFFECTIVE DATE:

October 1, 2025, except the provisions on the (1) return of provider payments and clinical peers are effective January 1, 2026, and (2) working group are effective upon passage.

§ 1 — THE RETURN OF HEALTH CARE PROVIDER PAYMENTS The bill prohibits a contracting health organization, more than 12 monthsafterreceivingaclean(i.e.complete)claim(insteadof18months as under current law), from canceling, denying, or demanding the return of full or partial payment for an authorized covered service due to administrative or eligibility error, unless the:

1.

organization (a) has a documented basis to believe that the provider fraudulently submitted the claim, (b) already paid the provider for the claim, or (c) paid a claim that should have been or was paid by a federal or state program;

or 2.

provider (a) did not bill the claim appropriately based on documentation or evidence of what medical service was actually providedor (b)receivedpayment fromadifferent insurer, payor, or administrator through coordination of benefits or subrogation or due to coverage under an automobile insurance or workers’ compensation policy.

By law, a contracting health organization must give a provider at least 30 days’ advance notice ofapayment cancellation,denial,or return demand.

Current law requires the notice to be sent by mail, e-mail, or fax.

The bill instead requires the organization to provide notice by certified mail, return receipt requested;

e-mail to an e-mail address the provider designated;

or fax.

Current law allows a provider to appeal a payment cancellation, sHB7039 / File No.

363 11 sHB7039 File No.

363 denial, or return demand within 30 days after receiving notice of it, in accordance with the organization’s procedures.

The bill specifies that an organization’s procedures must include an electronic appeal process.

The bill also requires an organization to notify the provider of its appeal decision within 10 business days after receiving the appeal.

If it fails to meet this deadline, the appeal is construed in favor of the provider.

§ 2 — WORKING GROUP ON COMPENSATING PHARMACISTS The bill requires the Insurance and Real Estate Committee’s chairpersons, or their designees, to convene an 11-member working group by July 1, 2025, to study and make legislative recommendations forcompensatinglicensedpharmacistswhoprovidehealthcare services (e.g.,HIVandinfluenzatesting,administeringvaccines,andprescribing contraception).

Required Membership The bill requires the working group to consist of the following members:

1.

the Insurance and Real Estate Committee chairpersons and ranking members, or their designees;

2.

the insurance and consumer protection commissioners, or their designees;

3.

two Connecticut-licensed pharmacists, one employed by an independentpharmacy(i.e.aprivatelyownedpharmacy withup to five stores in the state) and one employed by a chain pharmacy (i.e.

a community pharmacy that is publicly traded or has at least six stores in the state);

and 4.

one representative from each of the following:

an organization representing pharmacy benefit managers, a health insurer doing business in the state, and a pharmaceutical company doing business in the state.

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363 The bill requires all initial appointments to the working group to be made within 30 days after the bill’s effective date.

(Presumably the Insurance and Real Estate Committee chairpersons, or their designees, appoint the members, as they must convene the group.) The bill also requires the Insurance and Real Estate Committee’s administrative staff to be the working group’s administrative staff.

The working group must report its findings and legislative recommendations to the Insurance and Real Estate Committee by February 1, 2026.

It terminates when it submits its report or on February 1, 2026, whichever is later.

§ 3 — CLINICAL PEER QUALIFICATIONS Under PA 24-19 (§ 32),beginning January 1, 2026, clinical peers doing adverse determination reviews generally must have a nonrestricted license (in any U.S.

state) in the same specialty that typically manages themedicalcondition, procedure, or treatment under review.(Untilthat time, a clinical peer generally must have a nonrestricted license in the same or similar specialty.) Beginning January 1, 2026, the bill instead generally requires these clinical peers to have (1) a nonrestricted license in the same specialty as thetreating physicianor other healthcare professionalwho ismanaging the condition, procedure, or treatment under review or (2) substantial experience or expertise as a treating physician or other health care professional who typically manages the condition, procedure, or treatment under review.

However, only a physician may be a clinical peer when the health care professional managing the condition, procedure, or treatment under review is a physician.

By law, unchanged by the bill, for urgent care requests involving 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.

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363 §§ 4 & 5 — CUIPA VIOLATIONS FOR CERTAIN CARRIER CONDUCT By law, carriers must timely notify a health care provider when the carrier includes the provider in its provider network.

The bill also requires carriers to timely notify a provider in writing when the carrier has (1) denied the provider’s request to join the carrier’s network or (2) madeanychangetotheprovider’snetworkstatusforanyofthecarrier’s health benefit plans.

These notifications must explain the denial or other change.

The bill also requires a health carrier to make any decisions about a provider’s network status in good faith and not solely based on any potential financial impacts to the carrier.

The billmakesthefollowing carrier actionsunfair insurance practices under the Connecticut Unfair Insurance Practices Act (CUIPA) (see BACKGROUND):

1.

failure by a health carrier to make decisions in good faith based on its provider network’s composition, including accepting or denying a provider as a participating provider;

2.

failure to give written notice to a participating provider and his or her designated representative of any decision that impacts the provider’s network status, including an explanation of the decision;

3.

failure to promptly resolve any misunderstanding between the healthcarrierandaproviderabouttheprovider’snetworkstatus;

4.

failure to give a provider’s designated representative or contracting agent communications about the provider’s network status;

5.

attempting to interfere with the relationship between a participating provider and his or her designated representative or contracting agent;

and 6.

failure by a health carrier to adhere to the provisions of a written agreement or fee schedule in place with a participating provider sHB7039 / File No.

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363 or network of providers, or attempting to circumvent or misrepresent a written agreement or fee schedule.

Additionally, the bill makes a violation of the state’s network adequacy and continuity of care statute (see BACKGROUND) a CUIPA violation.

BACKGROUND CUIPA CUIPA prohibits engaging in unfair or deceptive acts or practices in the business of insurance.

It authorizes the insurance commissioner to conduct investigations and hearings, issue cease and desist orders, impose fines, revoke or suspend licenses, and order restitution for per se violations (i.e.

violations specifically listed in statute).

The law also allows the commissioner to ask the attorney general to seek injunctive relief in Superior Court if he believes someone is engaging in other unfair or deceptive acts not specifically defined in statute.

Fines may be up to (1) $5,000 per violation to a $50,000 maximum or (2)$25,000perviolationtoa$250,000maximuminanysix-monthperiod if the violation was knowingly committed.

The law also imposes a fine of up to $50,000, in addition to or in lieu of a license suspension or revocation, for violating a cease and desist order (CGS §§ 38a-815 to - 819).

Network Adequacy and Continuity of Care Under the network adequacy statute, a health carrier must establish and maintain a network that includes a sufficient number and appropriate types of participating providers, including those that serve predominantly low-income, medically underserved people, to assure that all covered benefits will be accessible to all the carrier’s covered persons without unreasonable travel or delay.

Covered persons must have access to emergency services and, if urgent crisis center services are available, urgent crisis center services, 24 hours a day, seven days a week.

The law requires health carriers to (1) make a good faith effort to give sHB7039 / File No.

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363 written notice to the patients of a participating provider who is leaving the carrier’s network and (2) provide for the continuity of care for patients in active courses of treatment with the provider so as to allow them to continue their treatments and transition to different participating providers.

It also generally requires health carriers and hospitals involved in a contract dispute to continue to abide by the terms of their contract, includingreimbursementterms,for60daysafteritexpiresorterminates (CGS § 38a-472f).

COMMITTEE ACTION Insurance and Real Estate Committee Joint Favorable Substitute Yea 10 Nay 3 (03/13/2025) sHB7039 / File No.

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