Chapter 700c

Sec. 38a-472f. *(See end of section for amended version of subsection (f) and effective date.) Network adequacy. Health carrier duties and responsibilities. Access plan filing. (a) As used in this section:

(1) “Authorized representative” means (A) an individual to whom a covered person has given express written consent to represent the covered person, (B) an individual authorized by law to provide substituted consent for a covered person, or (C) the covered person's treating health care provider when the covered person is unable to provide consent or a family member of the covered person;

(2) “Covered benefit” or “benefit” means those health care services to which a covered person is entitled under the terms of a health benefit plan;

(3) “Covered person” has the same meaning as provided in section 38a-591a;

(4) “Essential community provider” means a health care provider or facility that (A) serves predominantly low-income, medically underserved individuals and includes covered entities, as defined in 42 USC 256b, as amended from time to time, or (B) is described in 42 USC 1396r-8(c)(1)(D)(i)(IV), as amended from time to time;

(5) “Facility” has the same meaning as provided in section 38a-591a;

(6) (A) “Health benefit plan” means an insurance policy or contract, certificate or agreement offered, delivered, issued for delivery, renewed, amended or continued in this state to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services;

(B) “Health benefit plan” does not include:

(i) Coverage of the type specified in subdivisions (5) to (9), inclusive, (14) and (15) of section 38a-469 or any combination thereof;

(ii) Coverage issued as a supplement to liability insurance;

(iii) Liability insurance, including general liability insurance and automobile liability insurance;

(iv) Workers' compensation insurance;

(v) Automobile medical payment insurance;

(vi) Credit insurance;

(vii) Coverage for on-site medical clinics;

(viii) Other insurance coverage similar to the coverages specified in subparagraphs (B)(ii) to (B)(vii), inclusive, of this subdivision that are specified in regulations issued pursuant to the Health Insurance Portability and Accountability Act of 1996, P.L. 104-191, as amended from time to time, under which benefits for health care services are secondary or incidental to other insurance benefits;

(ix) (I) Benefits for long-term care, nursing home care, home health care, community-based care or any combination thereof, or (II) other similar, limited benefits that are specified in regulations issued pursuant to the Health Insurance Portability and Accountability Act of 1996, P.L. 104-191, as amended from time to time, provided any benefits specified in subparagraphs (B)(ix)(I) and (B)(ix)(II) of this subdivision are provided under a separate insurance policy, certificate or contract and are not otherwise an integral part of a health benefit plan; or

(x) Coverage of the type specified in subdivisions (3) and (13) of section 38a-469 or other fixed indemnity insurance if (I) such coverage is provided under a separate insurance policy, certificate or contract, (II) there is no coordination between the provision of the benefits and any exclusion of benefits under any group health plan maintained by the same plan sponsor, and (III) the benefits are paid with respect to an event without regard to whether benefits were also provided under any group health plan maintained by the same plan sponsor;

(7) “Health care provider” has the same meaning as provided in section 38a-477aa;

(8) “Health care services” has the same meaning as provided in section 38a-478;

(9) “Health carrier” has the same meaning as provided in section 38a-591a;

(10) “Intermediary” means a person, as defined in section 38a-1, authorized to negotiate and execute health care provider contracts with health carriers on behalf of health care providers or a network;

(11) “Network” means the group or groups of participating providers providing health care services under a network plan;

(12) “Network plan” means a health benefit plan that requires a covered person to use, or creates incentives, including financial incentives, for a covered person to use, health care providers or facilities that are managed, owned, under contract with or employed by the health carrier;

(13) “Participating provider” means a health care provider or a facility that, under a contract with a health carrier or such health carrier's contractor or subcontractor, has agreed to provide health care services to such health carrier's covered persons, with an expectation of receiving payment or reimbursement directly or indirectly from the health carrier, other than coinsurance, copayments or deductibles;

(14) “Primary care” means health care services for a range of common physical, mental or behavioral health conditions, provided by a health care provider;

(15) “Primary care provider” means a participating health care provider designated by a health carrier to supervise, coordinate or provide initial health care services or continuing health care services to a covered person, and who may be required by the health carrier to initiate a referral for specialty care and maintain supervision of health care services provided to the covered person;

(16) “Specialist” means a health care provider who (A) focuses on a specific area of physical, mental or behavioral health or a specific group of patients, and (B) has successfully completed required training and is recognized by this state to provide specialty care. “Specialist” includes a subspecialist who has additional training and recognition beyond that required for a specialist;

(17) “Specialty care” means advanced medically necessary care and treatment of specific physical, mental or behavioral health conditions, or those conditions that may manifest in particular ages or subpopulations, that are provided by a specialist in coordination with a health care provider; and

(18) “Tiered network” means a network that identifies and groups some or all types of health care providers and facilities into specific groups to which different participating provider reimbursement, covered person cost-sharing or participating provider access requirements, or any combination thereof, apply for the same health care services.

(b) The provisions of this section and sections 38a-477g and 38a-477h shall apply to all health carriers that deliver, issue for delivery, renew, amend or continue a network plan in this state.

(c) (1) (A) Each health carrier shall 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 individuals, to assure that all covered benefits will be accessible to all such health carrier's covered persons without unreasonable travel or delay.

(B) Covered persons shall have access to emergency services and, to the extent urgent crisis center services are available, urgent crisis center services, twenty-four hours a day, seven days a week. For the purposes of this subparagraph, “emergency services” and “urgent crisis center services” have the same meanings as provided in section 38a-477aa.

(2) The Insurance Commissioner shall determine the sufficiency of a health carrier's network in accordance with the provisions of this subsection and may establish sufficiency by reference to any reasonable criteria, including, but not limited to, (A) the ratio of participating providers to covered persons by specialty, (B) the ratio of primary care providers to covered persons, (C) the geographic accessibility of participating providers, (D) the geographic variation and dispersion of the state's population, (E) the wait times for appointments with participating providers, (F) the hours of operation of participating providers, (G) the ability of the network to meet the needs of covered persons that may include low-income individuals, children and adults with serious, chronic or complex conditions or physical or mental disabilities or individuals with limited English proficiency, (H) the availability of other health care delivery system options, such as centers of excellence and mobile clinics, (I) the volume of technological and specialty care services available to serve the needs of covered persons who require technologically advanced or specialty care services, (J) the extent to which participating health care providers are accepting new patients, (K) the degree to which (i) participating health care providers are authorized to admit patients to hospitals participating in the network, and (ii) hospital-based health care providers are participating providers, and (L) the regionalization of specialty care.

(d) (1) Each health carrier shall establish and maintain a process to ensure that a covered person receives a covered benefit at an in-network level, including an in-network level of cost-sharing, from a nonparticipating provider, or shall make other arrangements acceptable to the commissioner, when:

(A) The health carrier has a sufficient network but does not have (i) a type of participating provider available to provide the covered benefit to the covered person, or (ii) a participating provider available to provide the covered benefit to the covered person without unreasonable travel or delay; or

(B) The health carrier has an insufficient number or type of participating providers available to provide the covered benefit to the covered person without unreasonable travel or delay.

(2) Each health carrier shall disclose to a covered person the process to request a covered benefit from a nonparticipating provider, as provided under subdivision (1) of this subsection, when:

(A) The covered person is diagnosed with a condition or disease that requires specialty care; and

(B) The health carrier (i) does not have a participating provider of the required specialty with the professional training and expertise to treat or provide health care services for the condition or disease, or (ii) cannot provide reasonable access to a participating provider of the required specialty with the professional training and expertise to treat or provide health care services for the condition or disease without unreasonable travel or delay.

(3) The health carrier shall deem the health care services such covered person receives from a nonparticipating provider pursuant to subdivision (2) of this subsection to be health care services provided by a participating provider, including counting the covered person's cost-sharing for such health care services toward the maximum out-of-pocket expenses limit applicable to health care services received from participating providers under the health benefit plan.

(4) The health carrier shall ensure that the processes described under subdivisions (1) and (2) of this subsection address a covered person's request to obtain a covered benefit from a nonparticipating provider in a timely fashion appropriate to the covered person's condition. The time frames for such processes shall mirror those set forth in subsections (e) and (f) of section 38a-591g for external reviews of adverse determinations and final adverse determinations.

(5) The health carrier shall document all requests from its covered persons to obtain a covered benefit from a nonparticipating provider pursuant to this subsection and shall provide such documentation to the commissioner upon request.

(6) No health carrier shall use the process described in subdivisions (1) and (2) of this subsection as a substitute for establishing and maintaining a sufficient network as required under subsection (b) of this section. No covered person shall use such process to circumvent the use of covered benefits available through a health carrier's network delivery system options.

(7) Nothing in this subsection shall be construed to affect any rights or remedies available to a covered person under sections 38a-591a to 38a-591g, inclusive, or federal law relating to internal or external claims grievance and appeals processes.

(e) (1) Each health carrier shall:

(A) Maintain adequate arrangements to assure that such health carrier's covered persons have reasonable access to participating providers located near such covered persons' places of residence or employment. In determining whether a health carrier has complied with this subparagraph, the commissioner shall give due consideration to the availability of health care providers with the requisite expertise and training in the service area under consideration;

(B) Monitor on an ongoing basis the ability, clinical capacity and legal authority of its participating providers to provide all covered benefits to its covered persons;

(C) Establish and maintain procedures by which a participating provider will be notified on an ongoing basis of the specific covered health care services for which such participating provider will be responsible, including any limitations on or conditions of such services;

(D) Notify participating providers of their obligations, if any, (i) to collect applicable coinsurance, deductibles or copayments from covered persons pursuant to a covered person's health benefit plan, and (ii) to notify covered persons, prior to delivery of health care services if possible, of such covered persons' financial obligations for noncovered benefits;

(E) Establish and maintain procedures by which a participating provider may determine in a timely manner at the time benefits are provided whether an individual is a covered person or is within a grace period for payment of premium during which such health carrier may hold a claim for health care services pending receipt of payment of premium by such health carrier;

(F) Timely notify a health care provider or facility, when such health carrier has 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 status;

(G) Notify participating providers of the participating provider's responsibilities with respect to such health carrier's applicable administrative policies and programs, including, but not limited to, payment terms, utilization review, quality assessment and improvement programs, credentialing, grievance and appeals processes, date reporting requirements, reporting requirements for timely notice of changes in practice such as discontinuance of accepting new patients, confidentiality requirements, any applicable federal or state programs and obtaining necessary approval of referrals to nonparticipating providers; and

(H) Establish and maintain procedures for the resolution of administrative, payment or other disputes between the health carrier and a participating provider.

(2) No health carrier shall:

(A) Offer or provide an inducement to a participating provider that would encourage or otherwise incentivize a participating provider to provide less than medically necessary health care services to a covered person;

(B) Prohibit a participating provider from (i) discussing any specific or all treatment options with covered persons, irrespective of such health carrier's position on such treatment options, or (ii) advocating on behalf of covered persons within the utilization review or grievance and appeals processes established by such health carrier or a person contracting with such health carrier or in accordance with any rights or remedies available to covered persons under sections 38a-591a to 38a-591g, inclusive, or federal law relating to internal or external claims grievance and appeals processes; or

(C) Penalize a participating provider because such participating provider reports in good faith to state or federal authorities any act or practice by such health carrier that jeopardizes patient health or welfare.

*(f) (1) Each health carrier shall develop standards, to be used by such health carrier and its intermediaries, for selecting and tiering, as applicable, participating providers and each health care provider specialty.

(2) No health carrier shall establish selection or tiering criteria in a manner that would (A) allow the health carrier to discriminate against high-risk populations by excluding or tiering participating providers because they are located in a geographic area that contains populations or participating providers that present a risk of higher-than-average claims, losses or health care services utilization, or (B) exclude participating providers because they treat or specialize in treating populations that present a risk of higher-than-average claims, losses or health care services utilization. Nothing in this subdivision shall be construed to prohibit a health carrier from declining to select a health care provider or facility for participation in such health carrier's network who fails to meet legitimate selection criteria established by such health carrier.

(3) No health carrier shall establish selection criteria that would allow the health carrier to discriminate, with respect to participation in a network plan, against any health care provider who is acting within the scope of such health care provider's license or certification under state law. Nothing in this subdivision shall be construed to require a health carrier to contract with any health care provider or facility willing to abide by the terms and conditions for participation established by such health carrier.

(4) Each health carrier shall make the standards required under subdivision (1) of this subsection available to the commissioner for review and shall post on its Internet web site and make available to the public a plain language description of such standards.

(5) Nothing in this subsection shall require a health carrier, its intermediaries or health care provider networks with which such health carrier or intermediary contracts to (A) employ specific health care providers acting within the scope of such health care providers' license or certification under state law who meet such health carrier's selection criteria, or (B) contract with or retain more health care providers acting within the scope of such health care providers' license or certification under state law than are necessary to maintain a sufficient network.

(g) (1) (A) A health carrier and participating provider shall provide not less than ninety days' written notice to each other of any intent to terminate a contract between such health carrier and such participating provider prior to the proposed date of termination or, in the case of a nonrenewal, from the end of the contract period.

(B) A health carrier shall make a good faith effort to provide written notice, not less than thirty days before the proposed date of termination of the contract or, in the case of a nonrenewal, from the end of the contract period, to all covered persons who are patients being treated on a regular basis by or at the participating provider. The notice requirements set forth in this subparagraph shall not apply if the health carrier and participating provider agree, in writing, on an extension of such contract for a period not to exceed one year.

(C) For each contract entered into, renewed, amended or continued on or after July 1, 2023, between a health carrier and a participating provider that is a hospital, as defined in section 38a-493, or a parent corporation of a hospital or an intermediary of a hospital, if the contract is not renewed or is terminated by either the health carrier or the participating provider, the health carrier and the participating provider shall continue to abide by the terms of such contract, including reimbursement terms for all health care services and provisions provided under such contract, for a period of sixty days from the date of termination or, in the case of a nonrenewal, from the end of the contract period. Except as otherwise agreed between such health carrier and such participating provider, the reimbursement terms of any contract entered into by such health carrier and such participating provider during said sixty-day period shall be retroactive to the date of termination or, in the case of a nonrenewal, the end date of the contract period. This subparagraph shall not apply if the health carrier and participating provider agree, in writing, to the termination or nonrenewal of the contract and the health carrier and participating provider provide the notices required under subparagraphs (A) and (B) of this subdivision.

(2) (A) For the purposes of this subdivision:

(i) “Active course of treatment” means (I) a medically necessary, ongoing course of treatment for a life-threatening condition, (II) a medically necessary, ongoing course of treatment for a serious condition, (III) medically necessary care provided during the second or third trimester of pregnancy, or (IV) a medically necessary, ongoing course of treatment for a condition for which a treating health care provider attests that discontinuing care by such health care provider would worsen the covered person's condition or interfere with anticipated outcomes;

(ii) “Life-threatening condition” means a disease or condition for which the likelihood of death is probable unless the course of such disease or condition is interrupted;

(iii) “Serious condition” means a disease or condition that requires complex ongoing care such as chemotherapy, radiation therapy or postoperative visits, which the covered person is currently receiving; and

(iv) “Treating provider” means a covered person's treating health care provider or a facility at which a covered person is receiving treatment, that is removed from or leaves a health carrier's network pursuant to subdivision (1) of this subsection.

(B) (i) Each health carrier shall establish and maintain reasonable procedures to transition a covered person, who is in an active course of treatment with a participating health care provider or at a participating facility that becomes a treating provider, to another participating provider in a manner that provides for continuity of care.

(ii) In addition to the notice required under subparagraph (B) of subdivision (1) of this subsection, the health carrier shall provide to such covered person (I) a list of available participating providers in the same geographic area as such covered person who are of the same health care provider or facility type, and (II) the procedures for how such covered person may request continuity of care as set forth in this subparagraph.

(iii) Such procedures shall provide that:

(I) Any request for a continuity of care period shall be made by the covered person or the covered person's authorized representative;

(II) A request for a continuity of care period, made by a covered person who meets the requirements under subparagraph (B)(i) of this subdivision or such covered person's authorized representative and whose treating provider was not removed from or did not leave the network for cause, shall be reviewed by the health carrier's medical director after consultation with such treating provider; and

(III) For a covered person who is in the second or third trimester of pregnancy, the continuity of care period shall extend through the postpartum period.

(iv) The continuity of care period for a covered person who is undergoing an active course of treatment shall extend to the earliest of the following: (I) Termination of the course of treatment by the covered person or the treating provider; (II) ninety days after the date the participating provider is removed from or leaves the network, unless the health carrier's medical director determines that a longer period is necessary; (III) the date that care is successfully transitioned to another participating provider; (IV) the date benefit limitations under the health benefit plan are met or exceeded; or (V) the date the health carrier determines care is no longer medically necessary.

(v) The health carrier shall only grant a continuity of care period as provided under subparagraph (B)(iv) of this subdivision if the treating provider agrees, in writing, (I) to accept the same payment from such health carrier and abide by the same terms and conditions as provided in the contract between such health carrier and treating provider when such treating provider was a participating provider, and (II) not to seek any payment from the covered person for any amount for which such covered person would not have been responsible if the treating provider was still a participating provider.

(h) (1) (A) Beginning January 1, 2017, a health carrier shall file with the commissioner for review each existing network as of said date and an access plan for each such network.

(B) For each new network a health carrier intends to offer after January 1, 2017, such health carrier shall file with the commissioner for review, within thirty days prior to the date such health carrier will offer such new network, the new network and an access plan for such new network.

(C) A health carrier shall notify the commissioner of any material change to an existing network not later than fifteen business days after such change and shall file with the commissioner an update to such existing network not later than thirty days after such material change. For the purposes of this subparagraph, “material change” means (i) a change of twenty-five per cent or more in the participating providers in a health carrier's network or the type of participating providers available in a health carrier's network to provide health care services or specialty care to covered persons, or (ii) any change that renders a health carrier's network noncompliant with one or more network adequacy standards, including, but not limited to, (I) a significant reduction in the number of primary care or specialty care providers available in the network, (II) a reduction in a specific type of participating provider such that a specific covered benefit is no longer available to covered persons, (III) a change to a tiered, multitiered, layered or multilevel network plan structure, (IV) a change in inclusion of a major health system, as defined in section 19a-508c, that causes a network to be significantly different from what a covered person initially purchased, or (V) after notice, any other change the commissioner deems to be a material change.

(2) Each access plan required under subdivision (1) of this subsection shall be in a form and manner prescribed by the commissioner and shall contain descriptions of at least the following:

(A) The health carrier's procedures for making and authorizing referrals within and outside its network, if applicable;

(B) The health carrier's procedures for monitoring and assuring on an ongoing basis the sufficiency of its network to meet the health care needs of the populations that enroll in its network plans;

(C) The factors used by the health carrier to build its network, including a description of the network and the criteria used to select and tier health care providers and facilities;

(D) The health carrier's efforts to address the needs of covered persons, including, but not limited to, children and adults, including those with limited English proficiency or illiteracy, diverse cultural or ethnic backgrounds, physical or mental disabilities and serious, chronic or complex conditions. Such description shall include the health carrier's efforts, when appropriate, to include various types of essential community providers in its network;

(E) The health carrier's methods for assessing the health care needs of covered persons and covered persons' satisfaction with the health care services provided;

(F) The health carrier's method of informing covered persons of the network plan's covered benefits, including, but not limited to, (i) the network plan's grievance and appeals processes, (ii) the network plan's process for covered persons to choose or change participating providers in the network plan, (iii) the health carrier's process for updating its participating provider directories for each of its network plans, (iv) a statement of the health care services offered by the network plan, including those health care services offered through the preventive care benefit, if applicable, and (v) the network plan's procedures for covering and approving emergency, urgent and specialty care, if applicable;

(G) The health carrier's system for ensuring the coordination and continuity of care for covered persons (i) referred to specialty physicians, or (ii) using ancillary services that are covered benefits, including, but not limited to, social services and other community resources and for ensuring appropriate discharge planning for covered persons using such ancillary services;

(H) The health carrier's process for enabling covered persons to change their designation of a primary care provider, if applicable;

(I) The health carrier's proposed plan for providing continuity of care to covered persons in the event of contract termination between the health carrier and any of its participating providers or in the event of the health carrier's insolvency or other inability to continue operations. Such description shall explain how covered persons will be notified of such contract termination, insolvency or other cessation of operations and transitioned to other participating providers in a timely manner;

(J) The health carrier's process for monitoring access to specialist services in emergency room care, anesthesiology, radiology, hospitalist care and pathology and laboratory services at such health carrier's participating hospitals;

(K) The health carrier's efforts to ensure that its participating providers meet available and appropriate quality of care standards and health outcomes for network plans that such health carrier has designed to include health care providers and facilities that provide high quality of care and health outcomes;

(L) The health carrier's accreditation by the National Committee for Quality Assurance that such health carrier meets said committee's network adequacy requirements or by URAC that such health carrier meets URAC's provider network access and availability standards; and

(M) Any other information required by the commissioner to determine the health carrier's compliance with this section.

(3) A health carrier shall post each access plan on its Internet web site and make such access plan available at the health carrier's business premises in this state and to any person upon request, except that such health carrier may exclude from such posting or publicly available access plan any information such health carrier deems to be proprietary information that, if disclosed, would cause the health carrier's competitors to obtain valuable business information. A health carrier may request the commissioner not to disclose such information under section 1-210.

(i) (1) If the commissioner determines that (A) a health carrier has not contracted with a sufficient number of participating providers to assure that its covered persons have accessible health care services in a geographic area, (B) a health carrier's access plan does not assure reasonable access to covered benefits, (C) a health carrier has entered into a contract that does not conform to the requirements of this section or section 38a-477g, or (D) a health carrier has not complied with a provision of this section or section 38a-477g or 38a-477h, the health carrier shall modify its access plan or implement a corrective action plan, as appropriate, and as directed by the commissioner. The commissioner may take any other action authorized under this title to bring a health carrier into compliance with this section and sections 38a-477g and 38a-477h.

(2) The commissioner may adopt regulations, in accordance with the provisions of chapter 54, to implement the provisions of this section and sections 38a-477g and 38a-477h.

(P.A. 11-58, S. 17; P.A. 16-205, S. 1; P.A. 17-198, S. 31; P.A. 18-115, S. 1; P.A. 22-47, S. 52; P.A. 23-171, S. 22.)

*Note: On and after July 1, 2024, subsection (f) of this section, as amended by section 20 of public act 23-171, is to read as follows:

“(f) (1) Each health carrier shall develop standards, to be used by such health carrier and its intermediaries, for selecting and tiering, as applicable, participating providers and each health care provider specialty. Each contract involving a tiered network entered into, renewed or amended on or after July 1, 2024, between a health carrier and participating provider shall include a provision requiring that such health carrier provide to the participating provider, upon request, such participating provider's calculated score and related data, as available, and a description of the standards used for selecting and tiering such participating provider, including:

(A) Definitions and specifications of measures related to quality, cost, efficiency, satisfaction and any other factors used to develop such standards and measure performance under such standards, with delineation of any inclusions or exclusions under each measure;

(B) A defined time period of not less than one year to measure performance based on such standards; and

(C) A summary of the grievance process established pursuant to subdivision (2) of this subsection for a participating provider to appeal the results of such health carrier's tiering decisions and performance measures.

(2) The standards developed by each health carrier pursuant to subdivision (1) of this subsection shall remain in effect for not less than one year. Each health carrier shall (A) provide not less than ninety days' written notice to each participating provider before such health carrier may implement any changes to such standards and measures, and (B) establish a grievance process for a participating provider to appeal such health carrier's tiering decisions and performance measures for such participating provider.

(3) No health carrier shall establish selection or tiering criteria in a manner that would (A) allow the health carrier to discriminate against high-risk populations by excluding or tiering participating providers because they are located in a geographic area that contains populations or participating providers that present a risk of higher-than-average claims, losses or health care services utilization, or (B) exclude participating providers because they treat or specialize in treating populations that present a risk of higher-than-average claims, losses or health care services utilization. Nothing in this subdivision shall be construed to prohibit a health carrier from declining to select a health care provider or facility for participation in such health carrier's network who fails to meet legitimate selection criteria established by such health carrier.

(4) No health carrier shall establish selection criteria that would allow the health carrier to discriminate, with respect to participation in a network plan, against any health care provider who is acting within the scope of such health care provider's license or certification under state law. Nothing in this subdivision shall be construed to require a health carrier to contract with any health care provider or facility willing to abide by the terms and conditions for participation established by such health carrier.

(5) Each health carrier shall make the standards required under subdivision (1) of this subsection available to the commissioner for review and shall post on its Internet web site and make available to the public a plain language description of such standards, including all measures and corresponding definitions and specifications used to tier participating providers and to evaluate participating provider performance in each tier. Each health carrier shall post on its Internet web site a plain language description of the grievance process established pursuant to subdivision (2) of this subsection for a participating provider to appeal the results of such health carrier's tiering decisions and performance measures.

(6) Nothing in this subsection shall require a health carrier, its intermediaries or health care provider networks with which such health carrier or intermediary contracts to (A) employ specific health care providers acting within the scope of such health care providers' license or certification under state law who meet such health carrier's selection criteria, or (B) contract with or retain more health care providers acting within the scope of such health care providers' license or certification under state law than are necessary to maintain a sufficient network.”

(P.A. 11-58, S. 17; P.A. 16-205, S. 1; P.A. 17-198, S. 31; P.A. 18-115, S. 1; P.A. 22-47, S. 52; P.A. 23-171, S. 20, 22.)

History: P.A. 11-58 effective January 1, 2012; P.A. 16-205 replaced former provisions with provisions re definitions and health carriers' responsibilities and duties re network adequacy, effective January 1, 2017; P.A. 17-198 amended Subsec. (a)(6) by redefining “health benefit plan”, effective June 30, 2017; P.A. 18-115 amended Subsec. (g) by substituting “ninety days'” for “sixty days'” in Subdiv. (1)(A), adding Subdiv. (1)(C) re contracts between health carriers and participating providers that are hospitals or parent corporations of hospitals, and making a technical change in Subdiv. (2)(B)(ii), effective July 1, 2018; P.A. 22-47 amended Subsec. (c)(1)(B) by requiring that covered persons have access to urgent crisis center services, to the extent such services are available, and defined “emergency services” and “urgent crisis center services”, effective January 1, 2023; P.A. 23-171 amended Subsec. (g)(1)(A) by replacing provision re notice prior to contract termination and patient list requirement with provision requiring notice of any intent to terminate such contract, amended Subsec. (g)(1)(B) by replacing “after the health carrier receives or issues a written notice under subparagraph (A) of this subdivision” with “before the proposed date of termination of the contract or, in the case of a nonrenewal, from the end of the contract period”, deleting provision re termination or removal irrespective of whether such removal or departure is for cause, adding provision re notice requirements do not apply if the health carrier and participating provider agree on a contract extension, amended Subsec. (g)(1)(C) to extend the 60-day period beyond contract termination or nonrenewal for intermediaries of hospitals and made technical changes in Subsec. (g), effective June 27, 2023, and amended Subsec. (f)(1) by adding provision re health carriers provide, upon request, certain information used to tier participating providers, added new Subsec. (f)(2) re establishment, notice and grievance requirements for tiering standards, redesignated existing Subdivs. (2) to (5) as Subdivs. (3) to (6) and amended redesignated Subsec. (f)(5) re tiering information to be posted on health carrier's Internet web site, effective July 1, 2024.

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Sec. 38a-477d. Information to be made available to consumers. Explanations of benefits. Disclosures by health carriers. Specifications by consumers. Restrictions. (a) Each insurer, health care center, hospital service corporation, medical service corporation, fraternal benefit society or other entity that delivers, issues for delivery, renews, amends or continues a health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 in this state, shall:

(1) Make available to consumers, in an easily readable, accessible and understandable format:

(A) The following information for each such policy:

(i) Any coverage exclusions;

(ii) Any restrictions on the use or quantity of a covered benefit, including on prescription drugs or drugs administered in a physician's office or a clinic;

(iii) A specific description of how prescription drugs are included or excluded from any applicable deductible, including a description of other out-of-pocket expenses that apply to such drugs;

(iv) The specific dollar amount of any copayment and the percentage of any coinsurance imposed on each covered benefit, including each covered prescription drug; and

(v) Information regarding any process available to consumers, and all documents necessary, to seek coverage of a noncovered outpatient prescription drug; and

(B) With respect to explanations of benefits issued pursuant to subsections (d) to (i), inclusive, of this section, a statement disclosing that each consumer who is a covered individual and legally capable of consenting to the provision of covered benefits under such policy may specify that such insurer, center, corporation, society or entity, and each third-party administrator, as defined in section 38a-720, providing services to such insurer, center, corporation, society or entity, shall:

(i) Not issue explanations of benefits concerning covered benefits provided to such consumer; or

(ii) (I) Issue explanations of benefits concerning covered benefits provided to such consumer solely to such consumer; and

(II) Use a method specified by such consumer to issue such explanations of benefits solely to such consumer, and provide sufficient space in the statement for such consumer to specify a mailing address or an electronic mail address for such insurer, center, corporation, society, entity or third-party administrator to use to contact such consumer concerning covered benefits provided to such consumer.

(2) Make available to consumers a way to determine accurately:

(A) Whether a specific prescription drug is available under such policy's drug formulary;

(B) The coinsurance, copayment, deductible or other out-of-pocket expense applicable to such drug;

(D) Whether such drug requires prior authorization or the use of step therapy;

(E) Whether specific types of health care specialists are in-network; and

(F) Whether a specific health care provider or hospital is in-network.

(b) (1) Each insurer, health care center, hospital service corporation, medical service corporation, fraternal benefit society or other entity shall make the information and statement required under subsection (a) of this section available to consumers at the time of enrollment and shall post such information and statement on its Internet web site.

(2) The Connecticut Health Insurance Exchange, established pursuant to section 38a-1081, shall post links on its Internet web site to such information and statement for each qualified health plan that is offered or sold through the exchange.

(c) The Insurance Commissioner shall post links on the Insurance Department's Internet web site to any on-line tools or calculators to help consumers compare and evaluate health insurance policies and plans.

(d) Except as provided in subsection (g) of this section, each insurer, health care center, hospital service corporation, medical service corporation, fraternal benefit society or other entity that delivers, issues for delivery, renews, amends or continues a health insurance policy described in subsection (a) of this section, and each third-party administrator, as defined in section 38a-720, providing services to such an insurer, center, corporation, society or entity, shall:

(1) Issue explanations of benefits to consumers who are covered individuals under the policy; and

(2) Permit each consumer who is a covered individual under the policy and legally capable of consenting to the provision of covered benefits to specify, in writing, that such insurer, center, corporation, society, entity or third-party administrator issue explanations of benefits concerning covered benefits provided to such consumer solely to such consumer, and specify, in writing, which of the following methods such insurer, center, corporation, society, entity or third-party administrator shall use to issue such explanations of benefits solely to such consumer:

(A) Mailing such explanations of benefits to such consumer's mailing address or another mailing address specified by such consumer; or

(B) Making such explanations of benefits available to such consumer by electronic means and notifying such consumer by electronic means, including, but not limited to, electronic mail, when such insurer, center, corporation, society, entity or third-party administrator makes each such explanation of benefits available to such consumer by electronic means, provided making such explanations of benefits available to such consumer by electronic means and notifying such consumer by electronic means complies with all applicable federal and state laws and regulations concerning data security, including, but not limited to, 45 CFR Part 160, as amended from time to time, and 45 CFR Part 164, Subparts A and C, as amended from time to time.

(e) Each method specified by a consumer, in writing, pursuant to subdivision (2) of subsection (d) of this section shall be valid until the consumer submits a written specification to the insurer, center, corporation, society, entity or third-party administrator for a different method. Such insurer, center, corporation, society, entity or third-party administrator shall comply with a written specification under this subsection or subdivision (2) of subsection (d) of this section, as applicable, not later than three business days after such insurer, center, corporation, society, entity or third-party administrator receives such specification.

(f) Each insurer, center, corporation, society, entity or third-party administrator that receives a written specification from a consumer pursuant to subdivision (2) of subsection (d) of this section or subsection (e) of this section, as applicable, shall provide the consumer who made such specification with written confirmation that such insurer, center, corporation, society, entity or third-party administrator received such specification, and advise such consumer, in writing, regarding the status of such specification if such consumer contacts such insurer, center, corporation, society, entity or third-party administrator, in writing, regarding such specification.

(g) Each consumer who is a covered individual under a policy described in subsection (a) of this section and is legally capable of consenting to the provision of covered benefits may specify, in writing, that the insurer, center, corporation, society or entity that delivered, issued for delivery, renewed, amended or continued the policy, or a third-party administrator providing services to such insurer, center, corporation, society or entity, not issue explanations of benefits pursuant to subsections (d) to (f), inclusive, of this section if such explanations of benefits concern covered benefits that were provided to such consumer. Such insurer, center, corporation, society, entity or third-party administrator shall not require such consumer to provide any explanation regarding the basis for such consumer's specification, unless such explanation is required by applicable law or pursuant to an order issued by a court of competent jurisdiction.

(h) Each insurer, center, corporation, society or entity that delivers, issues for delivery, renews, amends or continues a policy described in subsection (a) of this section, and each third-party administrator providing services to such insurer, center, corporation, society or entity, shall disclose to each consumer who is a covered individual under the policy such consumer's ability to submit specifications pursuant to subsections (d) to (g), inclusive, of this section. Such disclosure shall be in plain language and displayed or printed, as applicable, clearly and conspicuously in all evidence of coverage documents, privacy communications, explanations of benefits and Internet web sites that are maintained by such insurer, center, corporation, society, entity or third-party administrator and accessible to consumers in this state.

(i) No insurer, center, corporation, society or entity that is subject to subsections (d) to (h), inclusive, of this section shall require a consumer or policyholder to waive any right to limit disclosure under subsections (d) to (h), inclusive, of this section as a precondition to delivering, issuing for delivery, renewing, amending or continuing a policy described in subsection (a) of this section to the consumer or policyholder. Nothing in this subsection or subsections (d) to (h), inclusive, of this section shall be construed to limit a consumer's or policyholder's ability to request review of an adverse determination.

(j) Notwithstanding the provisions with respect to explanation of benefits set forth in subsections (d) to (h), inclusive, of this section, each insurer, health care center, hospital service corporation, medical service corporation, fraternal benefit society or other entity that delivers, issues for delivery, renews, amends or continues a health insurance policy providing coverage shall permit each consumer who is a covered individual under the policy and legally capable of consenting to the provision of covered benefits under such policy to specify, in writing, that such insurer, health care center, hospital service corporation, medical service corporation, fraternal benefit society or other entity make all documents pertaining to coverage available by electronic means, provided making such documents available to such consumer by electronic means complies with all applicable federal and state laws and regulations concerning data security, including, but not limited to, 45 CFR Part 160, as amended from time to time, and 45 CFR Part 164, Subparts A and C, as amended from time to time.

(P.A. 15-146, S. 7; P.A. 17-15, S. 43, 44; P.A. 18-41, S. 11; P.A. 21-22, S. 1; P.A. 23-171, S. 21.)

History: P.A. 15-146 effective January 1, 2016; P.A. 17-15 made technical changes in Subsecs. (a)(2)(D) and (c); P.A. 18-41 amended Subsec. (a)(1) by adding “, accessible” and Subpara. (E) re coverage of noncovered outpatient prescription drugs, effective January 1, 2020; P.A. 21-22 amended Subsec. (a) by dividing existing Subdiv. (1) into Subdivs. (1) and (1)(A), redesignating existing Subdivs. (1)(A) to (1)(E) as Subdivs. (1)(A)(i) to (1)(A)(v), adding new Subdiv. (1)(B) re statement disclosing information re explanations of benefits and making technical and conforming changes, amended Subsec. (b) by adding references to statement and added Subsecs. (d) to (i) re explanations of benefits, disclosures and prohibitions, effective January 1, 2023; P.A. 23-171 added Subsec. (j) re covered individuals may request all documents pertaining to coverage be made available by electronic means.

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Sec. 38a-477i. *(Note: This section is effective July 1, 2024.) Contract provisions containing all-or-nothing clauses, anti-steering clauses, anti-tiering clauses or gas clauses prohibited. (a) As used in this section:

(1) “All-or-nothing clause” means any provision in a health care contract that:

(A) Requires the health carrier or health plan administrator to include all members of a health care provider in a network plan; or

(B) Requires the health carrier or health plan administrator to enter into any additional contract with an affiliate of the health care provider as a condition to entering into a contract with such health care provider;

(2) “Anti-steering clause” means any provision in a health care contract that restricts the ability of the health carrier or health plan administrator from encouraging an enrollee to obtain a health care service from a competitor of a hospital or health system, including offering incentives to encourage enrollees to utilize specific health care providers such as centers of excellence or any other pay-for-performance program;

(3) “Anti-tiering clause” means any provision in a health care contract that:

(A) Restricts the ability of the health carrier or health plan administrator to introduce and modify a tiered network plan or assign health care providers into tiers, including a network that tiers providers by cost or quality; or

(B) Requires the health carrier or health plan administrator to place all members of a health care provider in the same tier of a tiered network plan;

(4) “Gag clause” means any provision in a health care contract that:

(A) Restricts the ability of the health care provider, health carrier or health plan administrator to disclose any price or quality information, including, but not limited to, the allowed amount, negotiated rates or discounts, any fees for services or any other claim-related financial obligations included in the provider contract, to any governmental entity as authorized by law or such government entity's contractors or agents, any enrollee, any treating health care provider of an enrollee, plan sponsor or potential eligible enrollees and plan sponsors; or

(B) Restricts the ability of either any health care provider, health carrier or health plan administrator to disclose out-of-pocket costs to any enrollee;

(5) “Health benefit plan”, “network”, “network plan” and “tiered network” have the same meanings as provided in section 38a-472f;

(6) “Health care contract” means any contract, agreement or understanding, either orally or in writing, entered into, amended, restated or renewed between a health care provider and a health carrier, health plan administrator, plan sponsor or its contractors or agents for delivery of health care services to an enrollee of a health benefit plan;

(7) “Health care provider” means any for-profit or nonprofit entity, corporation or organization, parent corporation, member, affiliate, subsidiary or entity under common ownership that is or whose members are licensed or otherwise authorized by this state to furnish, bill for or receive payment for health care service delivery in the normal course of business, including, but not limited to, a health system, hospital, hospital-based facility, freestanding emergency department, imaging center, physician group with eight or more physicians, urgent care center, as defined in section 19a-493d, and any physician or physician group in a practice of fewer than eight physicians that is employed by or an affiliate of any hospital, medical foundation or insurance company;

(8) “Health carrier” has the same meaning as provided in section 38a-591a; and

(9) “Health plan administrator” means any third-party administrator who acts on behalf of a plan sponsor to administer a health benefit plan.

(b) No health care provider, health carrier, health plan administrator or any agent or other entity that contracts on behalf of a health care provider, health carrier, or health plan administrator, may offer, solicit, request, amend, renew or enter into a health care contract on or after July 1, 2024, that directly or indirectly includes any of the following provisions:

(1) An all-or-nothing clause;

(2) An anti-steering clause;

(3) An anti-tiering clause; or

(4) A gag clause.

(c) Any clause in a health care contract, written policy, written procedure or agreement entered into, renewed or amended on or after July 1, 2024, that is contrary to the provisions set forth in subsection (b) of this section shall be null and void. All remaining clauses of such health care contract, written policy, written procedure or agreement shall remain in effect for the duration of the contract term.

(d) Nothing in this section shall be construed to modify, reduce or eliminate the existing privacy protections and standards pursuant to the federal Health Insurance Portability and Accountability Act of 1996, P.L. 104-191, as amended from time to time, the federal Genetic Information Nondiscrimination Act of 2008, P.L. 110-233, as amended from time to time, or the federal Americans with Disabilities Act of 1990, 42 USC 12101, as amended from time to time.

(P.A. 23-171, S. 19.)

History: P.A. 23-171 effective July 1, 2024.

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PART Ia

HEALTH INSURANCE: MANAGED CARE

Sec. 38a-478c. Managed care organization's report to the commissioner: Data, reports and information required. (a) On or before May first of each year, each managed care organization shall submit to the commissioner:

(1) A report on its quality assurance plan that includes, but is not limited to, information on complaints related to providers and quality of care, on decisions related to patient requests for coverage and on prior authorization statistics. Statistical information shall be submitted in a format prescribed by the commissioner and in a manner permitting comparison across plans and shall include, but not be limited to: (A) The ratio of the number of complaints received to the number of enrollees; (B) a summary of the complaints received related to providers and delivery of care or services and the action taken on the complaint; (C) the ratio of the number of prior authorizations denied to the number of prior authorizations requested; (D) a list of health care services that required prior authorization in the prior calendar year; (E) the percentage of services that required prior authorization in the prior calendar year compared to the total overall number of services covered in the prior calendar year; (F) the number of utilization review determinations made by or on behalf of a managed care organization not to certify an admission, service, procedure or extension of stay, and the denials upheld and reversed on appeal within the managed care organization's utilization review procedure; (G) the percentage of those employers or groups that renew their contracts within the previous twelve months; and (H) notwithstanding the provisions of this subsection, on or before July first of each year, all data required by the National Committee for Quality Assurance for its Health Plan Employer Data and Information Set. If an organization does not provide information for the National Committee for Quality Assurance for its Health Plan Employer Data and Information Set, then it shall provide such other equivalent data as the commissioner may require by regulations adopted in accordance with the provisions of chapter 54. The commissioner shall find that the requirements of this subdivision have been met if the managed care plan has received a one-year or higher level of accreditation by the National Committee for Quality Assurance and has submitted the Health Plan Employee Data Information Set data required by subparagraph (H) of this subdivision;

(2) A model contract that contains the provisions currently in force in contracts between the managed care organization and preferred provider networks in this state, and the managed care organization and participating providers in this state and, upon the commissioner's request, a copy of any individual contracts between such parties, provided the contract may withhold or redact proprietary fee schedule information;

(3) A written statement of the types of financial arrangements or contractual provisions that the managed care organization has with hospitals, utilization review companies, physicians, preferred provider networks and any other health care providers including, but not limited to, compensation based on a fee-for-service arrangement, a risk-sharing arrangement or a capitated risk arrangement;

(4) Such information as the commissioner deems necessary to complete the consumer report card required pursuant to section 38a-478l. Such information may include, but need not be limited to: (A) The organization's characteristics, including its model, its profit or nonprofit status, its address and telephone number, the length of time it has been licensed in this and any other state, its number of enrollees and whether it has received any national or regional accreditation; (B) a summary of the information required by subdivision (3) of this subsection, including any change in a plan's rates over the prior three years, its state medical loss ratio and its federal medical loss ratio, as both terms are defined in section 38a-478l, how it compensates health care providers and its premium level; (C) a description of services, the number of primary care physicians and specialists, the number and nature of participating preferred provider networks and the distribution and number of hospitals, by county; (D) utilization review information, including the name or source of any established medical protocols and the utilization review standards; (E) medical management information, including the provider-to-patient ratio by primary care provider and specialty care provider, the percentage of primary and specialty care providers who are board certified, and how the medical protocols incorporate input as required in section 38a-478e; (F) the quality assurance information required to be submitted under the provisions of subdivision (1) of subsection (a) of this section; (G) the status of the organization's compliance with the reporting requirements of this section; (H) whether the organization markets to individuals and Medicare recipients; (I) the number of hospital days per thousand enrollees; and (J) the average length of hospital stays for specific procedures, as may be requested by the commissioner;

(5) A summary of the procedures used by managed care organizations to credential providers;

(6) A report on claims denial data for lives covered in the state for the prior calendar year, in a format prescribed by the commissioner, that includes: (A) The total number of claims received; (B) the total number of claims denied; (C) the total number of denials that were appealed; (D) the total number of denials that were reversed upon appeal; (E) (i) the reasons for the denials, including, but not limited to, “not a covered benefit”, “not medically necessary” and “not an eligible enrollee”, (ii) the total number of times each reason was used, and (iii) the percentage of the total number of denials each reason was used; and (F) other information the commissioner deems necessary; and

(7) A report, in a format prescribed by the commissioner, that contains a summary of (A) the actuarial analysis utilized in setting the standards for any procedures subject to prior authorization in the prior calendar year, and (B) any estimated premium savings that resulted from prior authorization and other utilization review protocols used in the prior calendar year.

(b) The information required pursuant to subsection (a) of this section shall be consistent with the data required by the National Committee for Quality Assurance (NCQA) for its Health Plan Employer Data and Information Set (HEDIS).

(c) The commissioner may accept electronic filing for any of the requirements under this section and may revise such filing requirements to facilitate implementation of the provisions of subdivision (1) of subsection (a) of this section.

(d) No managed care organization shall be liable for a claim arising out of the submission of any information concerning complaints concerning providers, provided the managed care organization submitted the information in good faith.

(e) The information required under subdivision (6) of subsection (a) of this section shall be posted on the Insurance Department's Internet web site.

(P.A. 97-99, S. 4; P.A. 98-27, S. 19; P.A. 03-169, S. 12; P.A. 09-46, S. 3; P.A. 10-5, S. 16; 10-19, S. 1; P.A. 11-58, S. 51; P.A. 15-118, S. 45, 46; P.A. 23-204, S. 228.)

History: P.A. 98-27 amended Subpara. (a)(1)(F) to add “Notwithstanding the provisions of this subsection, on or before July 1, 1998, and annually thereafter” re required data; P.A. 03-169 amended Subsec. (a) to reword Subdiv. (1)(D) re utilization review determinations, to add in Subdivs. (2) and (3) reference to preferred provider networks, to substitute “required” for “he is required to develop and distribute” in Subdiv. (4) and to add “the number and nature of participating preferred provider networks” in Subpara. (C), and make conforming changes; P.A. 09-46 amended Subsec. (a) to make a technical change and, in Subdiv. (4)(B), to replace provision re percentage of total premium revenues with definition of medical loss ratio in Sec. 38a-478l(b); P.A. 10-5 made a technical change in Subsec. (a)(1), effective May 5, 2010; P.A. 10-19 made a technical change in Subsec. (a)(1), added Subsec. (a)(6) re report on claims denial data and added Subsec. (e) re posting of data on Insurance Department's web site, effective July 1, 2010; P.A. 11-58 amended Subsec. (a) to add federal medical loss ratio to information provided to commissioner to complete consumer report card in Subdiv. (4) and to make technical changes, effective January 1, 2012; P.A. 15-118 made technical changes in Subsec. (a)(1) and (4); P.A. 23-204 amended Subsec. (a) to add “in a format prescribed by the commissioner and” re statistical information in Subdiv. (1), to add a new Subpara. (D) re prior authorization data reporting requirements, to redesignate existing Subparas. (D) to (F) as Subdiv. (F) to (H), to add Subdiv. (7) re report on actuarial analyses and premium savings relating to prior authorization and to make conforming changes and amended Subsec. (c) re commissioner may revise filing requirements to facilitate implementation of Subsec. (a)(1).

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Sec. 38a-478l. Consumer report card required. Content. Data analysis by commissioner. (a) Not later than October fifteenth of each year, the Insurance Commissioner, after consultation with the Commissioner of Public Health, shall develop and distribute a consumer report card on all managed care organizations. The commissioner shall develop the consumer report card in a manner permitting consumer comparison across organizations.

(b) (1) The consumer report card shall be known as the “Consumer Report Card on Health Insurance Carriers in Connecticut” and shall include (A) all health care centers licensed pursuant to chapter 698a, (B) the fifteen largest licensed health insurers that use provider networks and that are not included in subparagraph (A) of this subdivision, (C) the state medical loss ratio of each such health care center or licensed health insurer, (D) the federal medical loss ratio of each such health care center or licensed health insurer, (E) the information required under subdivisions (6) and (7) of subsection (a) of section 38a-478c, and (F) information concerning mental health services, as specified in subsection (c) of this section. The insurers selected pursuant to subparagraph (B) of this subdivision shall be selected on the basis of Connecticut direct written health premiums from such network plans.

(2) For the purposes of this section and sections 38a-477c, 38a-478c and 38a-478g:

(A) “State medical loss ratio” means the ratio of incurred claims to earned premiums for the prior calendar year for managed care plans issued in the state. Claims shall be limited to medical expenses for services and supplies provided to enrollees and shall not include expenses for stop loss coverage, reinsurance, enrollee educational programs or other cost containment programs or features;

(B) “Federal medical loss ratio” has the same meaning as provided in, and shall be calculated in accordance with, the Patient Protection and Affordable Care Act, P.L. 111-148, as amended from time to time, and regulations adopted thereunder.

(c) With respect to mental health services, the consumer report card shall include information or measures with respect to the percentage of enrollees receiving mental health services, utilization of mental health and chemical dependence services, inpatient and outpatient admissions, discharge rates and average lengths of stay. Such data shall be collected in a manner consistent with the National Committee for Quality Assurance Health Plan Employer Data and Information Set measures.

(d) The commissioner shall test market a draft of the consumer report card prior to its publication and distribution. As a result of such test marketing, the commissioner may make any necessary modification to its form or substance. The Insurance Department shall prominently display a link to the consumer report card on the department's Internet web site.

(e) The commissioner shall analyze annually the data submitted under subparagraphs (E) and (F) of subdivision (1) of subsection (b) of this section for the accuracy of, trends in and statistically significant differences in such data among the health care centers and licensed health insurers included in the consumer report card. The commissioner may investigate any such differences to determine whether further action by the commissioner is warranted.

(P.A. 97-99, S. 13; P.A. 06-188, S. 34; P.A. 07-217, S. 156; P.A. 09-46, S. 1; P.A. 10-19, S. 2; P.A. 11-58, S. 49; P.A. 13-3, S. 78; P.A. 15-118, S. 48; P.A. 23-204, S. 229.)

History: P.A. 06-188 added Subsec. (b)(3) re information concerning mental health services specified in new Subsec. (c), added new Subsec. (c) to require inclusion of specific mental health related information in consumer report card and redesignated existing Subsec. (c) as Subsec. (d); P.A. 07-217 made a technical change in Subsec. (c), effective July 12, 2007; P.A. 09-46 amended Subsec. (a) to replace provision re March 15 annual deadline with provision re October 15 annual deadline, amended Subsec. (b) to specify name by which consumer report card shall be known, define “medical loss ratio” and add same to list of information included in consumer report card, and amended Subsec. (d) to require Insurance Department to prominently display a link to consumer report card on its web site; P.A. 10-19 amended Subsec. (b) to add new Subdiv. (4) re information required under Sec. 38a-478c(a)(6) and redesignate existing Subdiv. (4) as Subdiv. (5), effective January 1, 2011; P.A. 11-58 amended Subsec. (b) to add requirement to include federal medical loss ratio in consumer report card, add definition of federal medical loss ratio and make conforming and technical changes, effective January 1, 2012; P.A. 13-3 added Subsec. (e) re data analysis by commissioner; P.A. 15-118 made a technical change in Subsec. (c); P.A. 23-204 amended Subsec. (b)(1) to add provision re new reporting requirements under Sec. 38a-478c(a)(7) be included in consumer report card.

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PART Id

HEALTH INSURANCE: PHARMACY BENEFITS MANAGERS

Sec. 38a-479jjj. Contract with 340B covered entity. Prohibited provisions. Reimbursement rates. Regulations. (a) For purposes of this section and section 19a-649:

(1) “340B covered entity” means an entity authorized to participate in the federal 340B Drug Pricing Program under 42 USC 256b(a)(4), as amended from time to time, and includes any pharmacy under contract with the entity to dispense drugs on behalf of the entity; and

(2) “Pharmacy benefits manager” has the same meaning as provided in section 38a-479aaa and includes a wholly or partially owned or controlled subsidiary of a pharmacy benefits manager.

(b) On and after January 1, 2024, a contract entered into between a pharmacy benefit manager and a 340B covered entity shall not contain any of the following provisions:

(1) A reimbursement rate for a prescription drug that is less than the reimbursement rate paid to pharmacies that are not 340B covered entities;

(2) A fee or adjustment that is not imposed on providers or pharmacies that are not 340B covered entities;

(3) A fee or adjustment amount that exceeds the fee or adjustment amount imposed on providers or pharmacies that are not 340B covered entities;

(4) Any provision that prevents or interferes with a patient's choice to receive a prescription drug from a 340B covered entity, including the administration of the drug; and

(5) Any provision that excludes a 340B covered entity from pharmacy benefit manager networks based on the 340B covered entity's participation in the federal 340B Drug Pricing Program.

(c) Except to the extent permitted by law, a pharmacy benefits manager may not consider whether an entity is a 340B covered entity when determining reimbursement rates.

(d) A pharmacy benefits manager may not retaliate against a 340B covered entity based on its exercise or any right or remedy under this section.

(e) To the extent that any contract provision contained in a contract between a pharmacy benefits manager and a 340B covered entity entered into, amended or renewed after January 1, 2024, violates any provision of subsection (b) or (c) of this section, such contract provision shall be void and unenforceable.

(f) The Insurance Commissioner may adopt regulations, in accordance with the provisions of chapter 54, to implement the provisions of this section.

(P.A. 23-171, S. 15.)

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PART II

INDIVIDUAL HEALTH INSURANCE

Sec. 38a-488b. Coverage for autism spectrum disorder therapies. (a) As used in this section:

(1) “Applied behavior analysis” means the design, implementation and evaluation of environmental modifications, using behavioral stimuli and consequences, including the use of direct observation, measurement and functional analysis of the relationship between environment and behavior, to produce socially significant improvement in human behavior.

(2) “Autism spectrum disorder services provider” means any person, entity or group that provides treatment for an autism spectrum disorder pursuant to this section.

(3) “Autism spectrum disorder” means “autism spectrum disorder” as set forth in the most recent edition of the American Psychiatric Association's “Diagnostic and Statistical Manual of Mental Disorders”.

(4) “Behavioral therapy” means any interactive behavioral therapies derived from evidence-based research and consistent with the services and interventions designated by the Commissioner of Social Services pursuant to subsection (e) of section 17a-215c, including, but not limited to, applied behavior analysis, cognitive behavioral therapy, or other therapies supported by empirical evidence of the effective treatment of individuals diagnosed with autism spectrum disorder, that are: (A) Provided to children less than twenty-one years of age; and (B) provided or supervised by (i) a licensed behavior analyst, (ii) a licensed physician, or (iii) a licensed psychologist. For the purposes of this subdivision, behavioral therapy is “supervised by” such licensed behavior analyst, licensed physician or licensed psychologist when such supervision entails at least one hour of face-to-face supervision of the autism spectrum disorder services provider by such licensed behavior analyst, licensed physician or licensed psychologist for each ten hours of behavioral therapy provided by the supervised provider.

(5) “Diagnosis” means the medically necessary assessment, evaluation or testing performed by a licensed physician, licensed psychologist or licensed clinical social worker to determine if an individual has autism spectrum disorder.

(b) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 that is delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for the diagnosis and treatment of autism spectrum disorder. For the purposes of this section and section 38a-482a, autism spectrum disorder shall be considered an illness.

(c) Such policy shall provide coverage for the following treatments, provided such treatments are (1) medically necessary, and (2) identified and ordered by a licensed physician, licensed psychologist or licensed clinical social worker for an insured who is diagnosed with autism spectrum disorder, in accordance with a treatment plan developed by a licensed behavior analyst, licensed physician, licensed psychologist or licensed clinical social worker, pursuant to a comprehensive evaluation or reevaluation of the insured:

(A) Behavioral therapy;

(B) Prescription drugs, to the extent prescription drugs are a covered benefit for other diseases and conditions under such policy, prescribed by a licensed physician, a licensed physician assistant or an advanced practice registered nurse for the treatment of symptoms and comorbidities of autism spectrum disorder;

(D) Direct psychological or consultative services provided by a licensed psychologist;

(E) Physical therapy provided by a licensed physical therapist;

(F) Speech and language pathology services provided by a licensed speech and language pathologist; and

(G) Occupational therapy provided by a licensed occupational therapist.

(d) Such policy shall not impose (1) any limits on the number of visits an insured may make to an autism spectrum disorder services provider pursuant to a treatment plan on any basis other than a lack of medical necessity, or (2) a coinsurance, copayment, deductible or other out-of-pocket expense for such coverage that places a greater financial burden on an insured for access to the diagnosis and treatment of autism spectrum disorder than for the diagnosis and treatment of any other medical, surgical or physical health condition under such policy.

(e) (1) Except for treatments and services received by an insured in an inpatient setting, an insurer, health care center, hospital service corporation, medical service corporation or fraternal benefit society may review a treatment plan developed as set forth in subsection (c) of this section for such insured, in accordance with its utilization review requirements, not more than once every six months unless such insured's licensed physician, licensed psychologist or licensed clinical social worker agrees that a more frequent review is necessary or changes such insured's treatment plan.

(2) For the purposes of this section, the results of a diagnosis shall be valid for a period of not less than twelve months, unless such insured's licensed physician, licensed psychologist or licensed clinical social worker determines a shorter period is appropriate or changes the results of such insured's diagnosis.

(f) Coverage required under this section may be subject to the other general exclusions and limitations of the individual health insurance policy, including, but not limited to, coordination of benefits, participating provider requirements, restrictions on services provided by family or household members and case management provisions, except that any utilization review shall be performed in accordance with subsection (e) of this section.

(g) (1) Nothing in this section shall be construed to limit or affect (A) any other covered benefits available to an insured under (i) such individual health insurance policy, (ii) section 38a-488a, or (iii) section 38a-490a, (B) any obligation to provide services to an individual under an individualized education program pursuant to section 10-76d, or (C) any obligation imposed on a public school by the Individual With Disabilities Education Act, 20 USC 1400 et seq., as amended from time to time.

(2) Nothing in this section shall be construed to require such individual health insurance policy to provide reimbursement for special education and related services provided to an insured pursuant to section 10-76d, unless otherwise required by state or federal law.

(P.A. 08-132, S. 1; P.A. 11-4, S. 6; P.A. 13-84, S. 1; June Sp. Sess. P.A. 15-5, S. 348; May Sp. Sess. P.A. 16-3, S. 55; June Sp. Sess. P.A. 17-2, S. 197; P.A. 23-204, S. 280.)

History: P.A. 08-132 effective January 1, 2009; P.A. 11-4 substituted “autism spectrum disorder” for “autism spectrum disorders”, effective May 9, 2011; P.A. 13-84 designated existing provisions as Subsec. (a) and amended same by adding provision re coverage for insured diagnosed with autism spectrum disorder prior to release of the fifth edition of the American Psychiatric Association's “Diagnostic and Statistical Manual of Mental Disorders” and by making a technical change, and added Subsec. (b) re same coverage provision, effective June 5, 2013; June Sp. Sess. P.A. 15-5 added new Subsec. (a) defining “applied behavior analysis”, “autism spectrum disorder services provider”, “autism spectrum disorder”, “behavioral therapy”, and “diagnosis”, redesignated existing Subsec. (a) as Subsec. (b) and amended same to add “diagnosis and”, delete references to physical therapy, speech therapy and occupational therapy services and the American Psychiatric Association's “Diagnostic and Statistical Manual of Mental Disorders”, delete provisions re limitation on coverage and add provision re autism spectrum disorder to be considered an illness, deleted former Subsec. (b) re maintaining coverage, added Subsec. (c) re coverage for treatments, added Subsec. (d) re prohibition on imposing limits on visits or out-of-pocket expenses, added Subsec. (e) re review of treatment plan and time period of validity of diagnostic results, added Subsec. (f) re exclusions from and limitations on coverage, and added Subsec. (g) re other covered benefits, obligations to provide services and obligations imposed on public schools and re reimbursement for special education and related services, effective January 1, 2016; May Sp. Sess. P.A. 16-3 amended Subsec. (a)(4) to replace “Commissioner of Developmental Services” with “Commissioner of Social Services”, effective July 1, 2016; June Sp. Sess. P.A. 17-2 amended Subsecs. (a)(4) and (c) to add references to licensed behavior analyst and delete references to certification of behavior analyst by Behavior Analyst Certification Board, effective July 1, 2018; P.A. 23-204 amended Subsec. (a)(4) by replacing reference to Sec. 17a-215c(l) with reference to Sec. 17a-215c(e), effective July 1, 2023.

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Sec. 38a-488e. Coverage for mental health wellness examinations. (a) For the purposes of this section:

(1) “Licensed mental health professional” means: (A) A licensed professional counselor or professional counselor, both as defined in section 20-195aa; (B) a person who is under professional supervision, as defined in section 20-195aa; (C) a physician licensed pursuant to chapter 370, who is certified in psychiatry by the American Board of Psychiatry and Neurology; (D) an advanced practice registered nurse licensed pursuant to chapter 378, who is certified as a psychiatric and mental health clinical nurse specialist or nurse practitioner by the American Nurses Credentialing Center; (E) a psychologist licensed pursuant to chapter 383; (F) a marital and family therapist licensed pursuant to chapter 383a; (G) a licensed clinical social worker licensed pursuant to chapter 383b; or (H) an alcohol and drug counselor licensed under chapter 376b; and

(2) “Mental health wellness examination” means a screening or assessment that seeks to identify any behavioral or mental health needs and appropriate resources for treatment. The examination may include: (A) Observation; (B) a behavioral health screening; (C) education and consultation on healthy lifestyle changes; (D) referrals to ongoing treatment, mental health services and other necessary supports; (E) discussion of potential options for medication; (F) age-appropriate screenings or observations to understand the mental health history, personal history and mental or cognitive state of the person being examined; and (G) if appropriate, relevant input from an adult through screenings, interviews or questions.

(b) (1) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 and delivered, issued for delivery, renewed, amended or continued in this state on or after January 1, 2023, (A) shall provide coverage for two mental health wellness examinations per year that are performed by a licensed mental health professional, and (B) shall not require prior authorization of such examinations.

(2) The mental health wellness examinations shall be covered with no patient cost sharing.

(c) The provisions of this section shall apply to a high deductible health plan, as that term is used in subsection (f) of section 38a-493, to the maximum extent permitted by federal law, except if such plan is used to establish a medical savings account or an Archer MSA pursuant to Section 220 of the Internal Revenue Code of 1986, as amended from time to time, or any subsequent corresponding Internal Revenue Code of the United States, as amended from time to time, or a health savings account pursuant to Section 223 of said Internal Revenue Code of 1986, as amended from time to time, the provisions of this section shall apply to such plan to the maximum extent that (1) is permitted by federal law, and (2) does not disqualify such account for the deduction allowed under said Section 220 or 223, as applicable.

(P.A. 22-47, S. 41; P.A. 23-148, S. 1.)

History: P.A. 22-47 effective January 1, 2023; P.A. 23-148 amended Subsec. (a) by deleting former Subdivs. (3) and (4) re definitions of “primary care provider” and “primary care”, amended Subsec. (b)(2) by deleting former Subpara. (A) re health wellness examinations provided by a primary care provider, and made technical and conforming changes throughout, effective June 26, 2023.

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Sec. 38a-489. (Formerly Sec. 38-174e). Continuation of coverage of mentally or physically handicapped children. (a) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (10), (11) and (12) of section 38a-469, delivered, issued for delivery, renewed, amended or continued in this state that provides that coverage of a dependent child shall terminate upon attainment of the limiting age for dependent children specified in the policy shall also provide in substance that attainment of the limiting age shall not operate to terminate the coverage of the child if at such date the child is and continues thereafter to be both (1) incapable of self-sustaining employment by reason of mental or physical handicap, as certified by the child's physician, physician assistant or advanced practice registered nurse on a form provided by the insurer, hospital service corporation, medical service corporation or health care center, and (2) chiefly dependent upon the policyholder or subscriber for support and maintenance.

(b) Proof of the incapacity and dependency shall be furnished to the insurer, hospital service corporation, medical service corporation or health care center by the policyholder or subscriber within thirty-one days of the child's attainment of the limiting age. The insurer, corporation or health care center may at any time require proof of the child's continuing incapacity and dependency. After a period of two years has elapsed following the child's attainment of the limiting age the insurer, corporation or health care center may require periodic proof of the child's continuing incapacity and dependency but in no case more frequently than once every year.

(1971, P.A. 408, S. 1, 2; P.A. 87-207, S. 1; P.A. 90-243, S. 79; P.A. 11-19, S. 33; P.A. 15-118, S. 4; P.A. 16-39, S. 57; P.A. 17-15, S. 50; P.A. 21-196, S. 62; P.A. 23-127, S. 3.)

History: P.A. 87-207 amended Subsecs. (a) and (b) to provide that for individual and group policies the continuation rights for children are applicable if the child is incapable of employment by reason of mental or physical handicap which has been certified by the child's physician; P.A. 90-243 substituted reference to “health insurance policy” for reference to hospital or medical expense policies and contracts, divided former Subsec. (a) into Subsecs. (a) and (b), added a reference to “health care center” and deleted former Subsec. (b) re group policies; Sec. 38-174e transferred to Sec. 38a-489 in 1991; P.A. 11-19 inserted “renewed, amended or continued” and made technical changes in Subsec. (a), effective January 1, 2012; P.A. 15-118 made technical changes; P.A. 16-39 amended Subsec. (a)(1) by adding reference to advanced practice registered nurse; P.A. 17-15 amended Subsec. (a) to delete “more than one hundred twenty days after July 1, 1971,”; P.A. 21-196 amended Subsec. (a) by adding reference to physician assistant; P.A. 23-127 deleted reference to Sec. 38a-469(6) re accident only coverage and made a technical change.

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Sec. 38a-490. (Formerly Sec. 38-174g). Coverage for newly born children. Notification to insurer. (a) Each individual health insurance policy delivered, issued for delivery, renewed, amended or continued in this state providing coverage of the type specified in subdivisions (1), (2), (4), (10), (11) and (12) of section 38a-469 for a family member of the insured or subscriber shall, as to such family member's coverage, also provide that the health insurance benefits applicable for children shall be payable with respect to a newly born child of the insured or subscriber from the moment of birth.

(b) Coverage for such newly born child shall consist of coverage for injury and sickness including necessary care and treatment of medically diagnosed congenital defects and birth abnormalities within the limits of the policy.

(c) If payment of a specific premium or subscription fee is required to provide coverage for a child, the policy or contract may require that notification of birth of such newly born child and payment of the required premium or fees shall be furnished to the insurer, hospital service corporation, medical service corporation or health care center not later than ninety-one days after the date of birth in order to continue coverage beyond such period, provided failure to furnish such notice or pay such premium or fees shall not prejudice any claim originating within such period.

(P.A. 74-6, S. 1–4; P.A. 90-243, S. 80; P.A. 11-19, S. 35; 11-171, S. 3; P.A. 12-145, S. 12; P.A. 23-127, S. 4; 23-204, S. 223.)

History: P.A. 90-243 substituted references to “health insurance policies” for references to hospital and medical expense policies and contracts, specified applicability to individual policies only, and applied provisions to “health care centers”; Sec. 38-174g transferred to Sec. 38a-490 in 1991; P.A. 11-19 inserted “delivered, issued for delivery, renewed, amended or continued in this state” and made a technical change in Subsec. (a), made technical changes in Subsec. (c), and deleted former Subsec. (d) re application of section to policies delivered or issued for delivery on or after October 1, 1974, or amended or renewed, effective January 1, 2012; P.A. 11-171 inserted “delivered, issued for delivery, renewed, amended or continued in this state” and made a technical change in Subsec. (a), increased time period for insured to notify insurer of birth of child and pay required premium or fee from 31 days to 61 days after birth and made technical changes in Subsec. (c), and deleted former Subsec. (d) re application of section to policies delivered or issued for delivery on or after October 1, 1974, or amended or renewed, effective January 1, 2012; P.A. 12-145 made a technical change in Subsec. (a), effective June 15, 2012; P.A. 23-127 deleted reference to Sec. 38a-469(6) re accident only coverage; P.A. 23-204 made identical change as P.A. 23-127 and amended Subsec. (c) by increasing time period for an insured to notify the insurer of birth of insured's child and pay required premium or fee from 61 days to 91 days after birth and made technical changes, effective January 1, 2024.

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Sec. 38a-492. (Formerly Sec. 38-174i). Coverage for accidental ingestion or consumption of controlled drugs. Benefits prescribed. No individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10) and (11) of section 38a-469 shall be delivered, issued for delivery or renewed in this state, or amended to substantially alter or change benefits or coverage, on or after July 1, 1975, unless persons covered under such policy will be eligible for benefits for expenses of emergency medical care arising from accidental ingestion or consumption of a controlled drug, as defined by section 21a-240, which are at least equal to the following minimum requirements: (1) In the case of benefits based upon confinement as an inpatient in a hospital, whether or not operated by the state, the period of confinement for which benefits shall be payable shall be at least thirty days in any calendar year. (2) For covered expenses incurred by the insured while other than an inpatient in a hospital, benefits shall be available for such expenses during any calendar year up to a maximum of five hundred dollars. For purposes of this section, the term “covered expenses” means the reasonable charges for treatment deemed necessary under generally accepted medical standards.

(P.A. 75-512, S. 1, 2; P.A. 85-613, S. 73, 154; P.A. 90-243, S. 82; P.A. 23-79, S. 47.)

History: P.A. 85-613 made technical change; P.A. 90-243 substituted reference to “health insurance policy” for reference to hospital and medical expense policies or contracts, specified applicability to individual policies only, and replaced alphabetic Subdiv. indicators with numeric ones; Sec. 38-174i transferred to Sec. 38a-492 in 1991; (Revisor's note: In 2001, a reference to “subsection (a) of” Sec. 38a-469 was deleted editorially by the Revisors for accuracy); P.A. 23-79 made a technical change, effective July 1, 2023.

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Sec. 38a-492a. Mandatory coverage for hypodermic needles and syringes. Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469, delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for hypodermic needles or syringes prescribed by a prescribing practitioner, as defined in section 20-571, for the purpose of administering medications for medical conditions, provided such medications are covered under the policy. Such benefits shall be subject to any policy provisions that apply to other services covered by such policy.

(P.A. 92-185, S. 4, 6; P.A. 95-264, S. 62; P.A. 11-19, S. 37; July Sp. Sess. P.A. 20-4, S. 9; P.A. 21-192, S. 10; P.A. 23-19, S. 14.)

History: P.A. 95-264 substituted “prescribing practitioner” for “licensed practitioner” (Revisor's note: The reference to “prescribing practitioner, as defined in subdivision (21) of ...” was changed editorially by the Revisors to “prescribing practitioner, as defined in subdivision (22) of ...”); P.A. 11-19 inserted “amended or continued” and made technical changes, effective January 1, 2012; July Sp. Sess. P.A. 20-4 substituted reference to Sec. 20-571(24) for reference to Sec. 20-571(22), effective January 1, 2021; P.A. 21-192 substituted reference to Sec. 20-571(28) for reference to Sec. 20-571(24), effective July 13, 2021; P.A. 23-19 made a conforming change, effective July 1, 2023.

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Sec. 38a-492v. Mandatory coverage for hospice services provided in home through a hospice care program to the extent provided for inpatient hospice services. (a) As used in this section, “hospice care program” has the same meaning as provided in section 19a-122e.

(b) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for hospice services provided to an insured in the home through a hospice care program, to the extent coverage is provided for inpatient hospice services in a hospital. Such coverage shall be subject to the same terms and conditions applicable to all other benefits under such policy.

(c) No such policy shall exclude a hospice service for coverage solely because such hospice service is provided in the home and not at a hospital, provided hospice care in the home is appropriate for the insured.

(d) Nothing in this section shall prohibit or limit a health insurer, health care center, hospital service corporation, medical service corporation or other entity from conducting utilization review for in-home hospice services, provided such utilization review is conducted in the same manner and uses the same clinical review criteria as a utilization review for the same hospice services provided in a hospital.

(P.A. 23-174, S. 3.)

History: P.A. 23-174 effective January 1, 2024.

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Sec. 38a-497. (Formerly Sec. 38-174r). Termination of coverage of child, stepchild, or other dependent child in individual policies. Dental or vision coverage. (a) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (10), (11) and (12) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state shall provide that coverage of a child, stepchild or other dependent child shall terminate not earlier than the policy anniversary date after the date on which the child, stepchild or other dependent child attains the age of twenty-six.

(b) Each individual health insurance policy described in subsection (a) of this section, and each individual health insurance policy providing coverage of the type specified in subdivision (16) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state, that includes or provides dental or vision coverage shall provide that dental or vision coverage of a child, stepchild or other dependent child shall terminate not earlier than the policy anniversary date after the date on which the child, stepchild or other dependent child attains the age of twenty-six.

(c) Each policy subject to this section shall cover a stepchild or other dependent child on the same basis as a biological child.

(d) Coverage for a child, stepchild or other dependent child under an insurance policy provided by the Comptroller for state employees or nonstate public employees pursuant to section 5-259 shall terminate not earlier than the end of the calendar year of the year in which the first of the following occurs: (1) The date such child, stepchild or other dependent child becomes covered under a group health plan through such dependent child's own employment; or (2) the date on which such dependent child attains the age of twenty-six.

(e) The provisions of subsection (d) of this section shall apply to insurance policies delivered, issued for delivery, amended, renewed or continued on or after July 1, 2022.

(P.A. 82-143; P.A. 90-243, S. 87; P.A. 07-185, S. 16; June Sp. Sess. P.A. 07-2, S. 64, 69; P.A. 08-147, S. 8; P.A. 09-124, S. 1; P.A. 11-58, S. 37; P.A. 21-149, S. 1; P.A. 22-118, S. 170; P.A. 23-127, S. 5.)

History: P.A. 90-243 substituted reference to health insurance policies for reference to hospital or medical expense policies and contracts and specified applicability solely to individual policies; Sec. 38-174r transferred to Sec. 38a-497 in 1991; P.A. 07-185 prohibited termination of coverage of a child prior to the policy anniversary date on or after the earliest of the date on which the child marries, ceases to be a resident of the state or attains the age of 26, for any policy delivered, issued for delivery, amended or renewed on or after October 1, 2007, effective July 1, 2007; June Sp. Sess. P.A. 07-2 changed effective date of P.A. 07-185, S. 16 to January 1, 2009, effective June 26, 2007, and applied provisions to policies delivered, issued for delivery, amended or renewed in this state on or after January 1, 2009, and made provisions allowing children to maintain coverage until age 26 contingent upon children remaining state residents, except for full-time attendance at an out-of-state accredited institution of higher education or residency with a custodial parent pursuant to a child custody determination, effective January 1, 2009; P.A. 08-147 revised conditions upon which coverage of a child terminates by adding provision re coverage under a group health plan through a dependent child's own employment, deleting custodial parent provision, and specifying that dependent children to age 19 are exempt from state residency requirement, effective January 1, 2009; P.A. 09-124 inserted “or continued”, made a technical change and added requirement that a stepchild be covered on the same basis as a biological child, effective June 18, 2009; P.A. 11-58 deleted requirements for termination of dependent coverage re marriage and state residency of a child, and made a technical change, effective July 2, 2011; P.A. 21-149 designated existing provisions re health insurance coverage for child as Subsec. (a) and amended same to add references to stepchild or other dependent child, delete provision re child becoming covered under group health plan through dependent's employment, and make technical and conforming changes, added Subsec. (b) re provisions re policy providing single ancillary dental or vision coverage, and designated existing provision requiring coverage of stepchild on same basis as biological child as Subsec. (c) and amended same to add reference to other dependent child and make technical changes, effective January 1, 2022; P.A. 22-118 added Subsec. (d) re insurance coverage for dependent child under Comptroller policy to terminate at end of calendar year of year dependent child becomes covered through own employment or attains age 26 and added Subsec. (e) re provisions of Subsec. (d) apply to policies delivered, amended, renewed or continued on or after July 1, 2022, effective July 1, 2022; P.A. 23-127 deleted reference to Sec. 38a-496(6) re accident only coverage.

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Sec. 38a-508. Coverage for adopted children. (a) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (10), (11) and (12) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state shall provide coverage for a child legally placed for adoption with the insured or subscriber who is an adoptive parent or a prospective adoptive parent, even though the adoption has not been finalized, provided the child lives in the household of such insured or subscriber and the child is dependent upon such person for support and maintenance.

(b) Coverage for such child legally placed for adoption shall consist of coverage for injury and sickness including necessary care and treatment of medically diagnosed congenital defects and birth abnormalities within the limits of the policy.

(c) If payment of a specific premium or subscription fee is required to provide coverage for a child legally placed for adoption with the insured or subscriber who is an adoptive parent or a prospective adoptive parent, the policy or contract may require that notification of acceptance of such child and payment of the required premium or fees be furnished to the insurer, hospital service corporation, medical service corporation or health care center within thirty-one days after the acceptance of such child in order to continue coverage beyond such thirty-one-day period, provided failure to furnish such notice or pay such premium or fees shall not prejudice any claim originating within such thirty-one-day period.

(d) Such policy (1) shall cover such child legally placed for adoption on the same basis as other dependents, and (2) may not contain any provision concerning preexisting conditions, insurability, eligibility or health underwriting approval for a child legally placed for adoption, except that an insurer, hospital service corporation, medical service corporation or health care center may require health underwriting for a child legally placed for adoption if a required premium or subscription fee and completed application materials are not provided to the insurer, hospital service corporation, medical service corporation or health care center before the expiration of the thirty-one-day period following the date the child was legally placed for adoption.

(P.A. 91-97, S. 1; P.A. 02-96, S. 1; P.A. 03-70, S. 1; P.A. 15-118, S. 10; P.A. 23-127, S. 6.)

History: P.A. 02-96 amended Subsec. (a) to substitute “each” for “every” and “amended, renewed or continued in this state” for “amended or renewed in this state on or after October 1, 1991,” and added Subsec. (d) re coverage and prohibited provisions; P.A. 03-70 amended Subsec. (d) to add exception re health underwriting if required premium or subscription fee and completed application materials are not provided before expiration of thirty-one-day period; P.A. 15-118 made technical changes in Subsecs. (c) and (d); P.A. 23-127 deleted reference to Sec. 38a-469(6) re accident only coverage.

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Sec. 38a-509. Mandatory coverage for infertility diagnosis and treatment. Limitations. (a) Subject to the limitations set forth in subsection (b) of this section and except as provided in subsection (c) of this section, each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state on or after January 1, 2018, shall provide coverage for the medically necessary expenses for the diagnosis and treatment of infertility, including, but not limited to, ovulation induction, intrauterine insemination, in-vitro fertilization, uterine embryo lavage, embryo transfer, gamete intra-fallopian transfer, zygote intra-fallopian transfer and low tubal ovum transfer. For purposes of this section, “infertility” means the condition of an individual who is unable to conceive or produce conception or sustain a successful pregnancy during a one-year period or such treatment is medically necessary.

(b) Such policy may:

(1) Limit such coverage for ovulation induction to a lifetime maximum benefit of four cycles;

(2) Limit such coverage for intrauterine insemination to a lifetime maximum benefit of three cycles;

(3) Limit such coverage for lifetime benefits to a maximum of two cycles, with not more than two embryo implantations per cycle, for in-vitro fertilization, gamete intra-fallopian transfer, zygote intra-fallopian transfer or low tubal ovum transfer, provided each such fertilization or transfer shall be credited toward such maximum as one cycle;

(4) Limit coverage for in-vitro fertilization, gamete intra-fallopian transfer, zygote intra-fallopian transfer and low tubal ovum transfer to those individuals who have been unable to conceive or produce conception or sustain a successful pregnancy through less expensive and medically viable infertility treatment or procedures covered under such policy. Nothing in this subdivision shall be construed to deny the coverage required by this section to any individual who foregoes a particular infertility treatment or procedure if the individual's physician determines that such treatment or procedure is likely to be unsuccessful; and

(5) Require that covered infertility treatment or procedures be performed at facilities that conform to the standards and guidelines developed by the American Society of Reproductive Medicine or the Society of Reproductive Endocrinology and Infertility.

(c) (1) Any insurance company, hospital service corporation, medical service corporation or health care center may issue to a religious employer an individual health insurance policy that excludes coverage for methods of diagnosis and treatment of infertility that are contrary to the religious employer's bona fide religious tenets.

(2) Upon the written request of an individual who states in writing that methods of diagnosis and treatment of infertility are contrary to such individual's religious or moral beliefs, any insurance company, hospital service corporation, medical service corporation or health care center may issue to or on behalf of the individual a policy or rider thereto that excludes coverage for such methods.

(d) Any health insurance policy issued pursuant to subsection (c) of this section shall provide written notice to each insured or prospective insured that methods of diagnosis and treatment of infertility are excluded from coverage pursuant to said subsection. Such notice shall appear, in not less than ten-point type, in the policy, application and sales brochure for such policy.

(e) As used in this section, “religious employer” means an employer that is a “qualified church-controlled organization”, as defined in 26 USC 3121 or a church-affiliated organization.

(f) Except as provided in subsections (c) to (e), inclusive, of this section, no individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state on or after January 1, 2024, may make any distinction or discrimination between persons on the basis of gender identity or expression, sexual orientation or age with respect to health insurance coverage for the medically necessary expenses for the diagnosis and treatment of infertility, except that such policy may consider age as a factor on the basis of a determination of medical necessity, using professional guidelines published by the American Society for Reproductive Medicine, its successor organization or a comparable organization. For purposes of this subsection, “gender identity or expression” has the same meaning as provided in section 1-1n.

(P.A. 05-196, S. 1; P.A. 15-118, S. 11; P.A. 17-55, S. 1; P.A. 23-127, S. 11.)

History: P.A. 15-118 made technical changes in Subsec. (c); P.A. 17-55 amended Subsec. (a) by replacing “October 1, 2005,” with “January 1, 2018,” replacing “a presumably healthy individual” with “an individual”, and adding “or such treatment is medically necessary”, effective January 1, 2018; P.A. 23-127 amended Subsec. (b) by deleting former Subdiv. (1) re coverage limited until such individual's fortieth birthday, redesignating existing Subdivs. (2) to (6) as Subdivs. (1) to (5), deleting former Subdiv. (7) re coverage limited to individuals who maintained coverage under such policy for 12 months, deleting former Subdiv. (8) re required disclosure to individual's health carrier of previous infertility treatment or procedures under different policy, added Subsec. (f) re prohibiting discrimination or distinction on the basis of gender identity or expression, sexual orientation or age with respect to coverage for infertility diagnosis and treatment, except that age may be considered a factor on basis of a determination of medical necessity and made technical and conforming changes in Subsecs. (a) and (b).

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Sec. 38a-510. Prescription drug coverage. Mail order pharmacies. Step therapy use. (a) No insurance company, hospital service corporation, medical service corporation, health care center or other entity delivering, issuing for delivery, renewing, amending or continuing an individual health insurance policy or contract that provides coverage for prescription drugs may:

(1) Require any person covered under such policy or contract to obtain prescription drugs from a mail order pharmacy as a condition of obtaining benefits for such drugs; 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 days, (B) for a prescribed drug for cancer treatment for an insured who has been diagnosed with stage IV metastatic cancer provided such prescribed drug is in compliance with approved federal Food and Drug Administration indications, or (C) for the period commencing January 1, 2024, and ending January 1, 2027, inclusive, for the treatment of schizophrenia, major depressive disorder or bipolar disorder, as defined in the most recent edition of the American Psychiatric Association's “Diagnostic and Statistical Manual of Mental Disorders”.

(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. If such provider does not deem such step therapy drug regimen clinically ineffective or has not requested an override pursuant to subdivision (1) of subsection (b) of this section, such drug regimen may be continued. For purposes 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 period set forth in 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, based on medical necessity.

(2) Upon the granting of an override request, 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.

(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.

(P.A. 05-233, S. 1; P.A. 14-118, S. 1; P.A. 17-228, S. 1; P.A. 23-204, S. 225.)

History: P.A. 05-233 effective July 1, 2005; P.A. 14-118 amended Subsec. (a) to designate existing provision re mail order pharmacy as Subdiv. (1) and add Subdiv. (2) re step therapy, deleted former Subsec. (b) re application of section, added new Subsec. (b) re step therapy override, added Subsec. (c) re effect of section on Secs. 38a-591c to 38a-591g and 38a-492i, and made technical and conforming changes, effective January 1, 2015; P.A. 17-228 amended Subsec. (a) to designate existing provisions re prescribed drug for longer than 60 days as Subpara. (A), and add Subpara. (B) re prescribed drug for cancer treatment in Subdiv. (2), designate existing provisions re deeming step therapy drug regimen clinically ineffective as Subdiv. (3) and amended same to add reference to Subdiv. (2), and make technical changes, effective January 1, 2018; P.A. 23-204 amended Subsec. (a) by substituting 30 days for 60 days in Subdiv. (2)(A), adding Subdiv. (2)(C) re step therapy prescription drug prohibition for treatment of schizophrenia, major depressive disorder and bipolar disorder from January 1, 2024, to January 1, 2027, and made technical and conforming changes, effective January 1, 2024.

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PART III

GROUP HEALTH INSURANCE

Sec. 38a-512b. Termination of coverage of child, stepchild or other dependent child in group policies. Dental or vision coverage. (a) Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (10), (11) and (12) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state shall provide that coverage of a child, stepchild or other dependent child shall terminate not earlier than the policy anniversary date after the date on which the child, stepchild or other dependent child attains the age of twenty-six.

(b) Each group health insurance policy described in subsection (a) of this section, and each group health insurance policy providing coverage of the type specified in subdivision (16) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state, that includes or provides dental or vision coverage shall provide that dental or vision coverage of a child, stepchild or other dependent child shall terminate not earlier than the policy anniversary date after the date on which the child, stepchild or other dependent child attains the age of twenty-six.

(c) Each policy subject to this section shall cover a stepchild or other dependent child on the same basis as a biological child.

(e) The provisions of subsection (d) of this section shall apply to insurance policies delivered, issued for delivery, amended, renewed or continued on or after July 1, 2022.

(P.A. 11-58, S. 38; P.A. 21-149, S. 2; P.A. 22-118, S. 171; P.A. 23-127, S. 7.)

History: P.A. 11-58 effective July 2, 2011; P.A. 21-149 designated existing provisions re health insurance coverage for child as Subsec. (a) and amended same to add references to stepchild or other dependent child, delete provision re child becoming covered under group health plan through dependent's employment, and make technical and conforming changes, added Subsec. (b) re provisions re policy providing single ancillary dental or vision coverage, and designated existing provision requiring coverage of stepchild on same basis as biological child as Subsec. (c) and amended same to add reference to other dependent child and make technical changes, effective January 1, 2022; P.A. 22-118 added Subsec. (d) re insurance coverage for dependent child under Comptroller policy to terminate at end of calendar year of year dependent child becomes covered through own employment or attains age 26 and added Subsec. (e) re provisions of Subsec. (d) apply to policies delivered, amended, renewed or continued on or after July 1, 2022, effective July 1, 2022; P.A. 23-127 deleted reference to Sec. 38a-469(6) re accident only coverage.

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Sec. 38a-514b. Coverage for autism spectrum disorder. (a) As used in this section:

(2) “Autism spectrum disorder services provider” means any person, entity or group that provides treatment for autism spectrum disorder pursuant to this section.

(b) Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 that is delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for the diagnosis and treatment of autism spectrum disorder. For the purposes of this section and section 38a-513c, autism spectrum disorder shall be considered an illness.

(A) Behavioral therapy;

(D) Direct psychological or consultative services provided by a licensed psychologist;

(E) Physical therapy provided by a licensed physical therapist;

(F) Speech and language pathology services provided by a licensed speech and language pathologist; and

(G) Occupational therapy provided by a licensed occupational therapist.

(f) Coverage required under this section may be subject to the other general exclusions and limitations of the group health insurance policy, including, but not limited to, coordination of benefits, participating provider requirements, restrictions on services provided by family or household members and case management provisions, except that any utilization review shall be performed in accordance with subsection (e) of this section.

(g) (1) Nothing in this section shall be construed to limit or affect (A) any other covered benefits available to an insured under (i) such group health insurance policy, (ii) section 38a-514, or (iii) section 38a-516a, (B) any obligation to provide services to an individual under an individualized education program pursuant to section 10-76d, or (C) any obligation imposed on a public school by the Individual With Disabilities Education Act, 20 USC 1400 et seq., as amended from time to time.

(2) Nothing in this section shall be construed to require such group health insurance policy to provide reimbursement for special education and related services provided to an insured pursuant to section 10-76d, unless otherwise required by state or federal law.

(P.A. 08-132, S. 2; P.A. 09-115, S. 1; P.A. 11-4, S. 7; P.A. 12-145, S. 20; P.A. 13-84, S. 2; June Sp. Sess. P.A. 15-5, S. 347; May Sp. Sess. P.A. 16-3, S. 54; June Sp. Sess. P.A. 17-2, S. 198; P.A. 23-204, S. 281.)

History: P.A. 08-132 effective January 1, 2009; P.A. 09-115 designated existing provisions as Subsec. (b) and amended same by changing coverage from “for physical therapy, speech therapy and occupational therapy services” to “the diagnosis and treatment” of autism spectrum disorders, making conforming changes and adding provision re autism spectrum disorder to be considered an illness, and added Subsec. (a) re definitions, Subsec. (c) re types of treatment and Subsecs. (d) to (h) re limits on coverage, review and exceptions, effective January 1, 2010; P.A. 11-4 amended Subsec. (a)(3) by substituting “pervasive developmental disorder” for “pervasive developmental disorders” and by making a technical change, and amended Subsecs. (a) to (c) by substituting “autism spectrum disorder” for “autism spectrum disorders”, effective May 9, 2011; P.A. 12-145 made a technical change in Subsec. (a)(4), effective June 15, 2012; P.A. 13-84 amended Subsec. (b) by adding provision re coverage for insured diagnosed with autism spectrum disorder prior to release of the fifth edition of the American Psychiatric Association's “Diagnostic and Statistical Manual of Mental Disorders”, and added Subsec. (i) re same coverage provision, effective June 5, 2013; June Sp. Sess. P.A. 15-5 amended Subsec. (a) to replace “autism services provider” with “autism spectrum disorder services provider” in Subdiv. (2), redefine “autism spectrum disorder” in Subdiv. (3) and redefine “behavioral therapy” in Subdiv. (4), amended Subsec. (b) to delete coverage exception provisions, amended Subsec. (c) to add reference to behavior analyst certified by Behavior Analyst Certification Board, deleted former Subdiv. (d) re limit on coverage, redesignated existing Subsec. (e) as Subsec. (d) and amended same to insert “spectrum disorder”, redesignated existing Subsecs. (f) to (h) as Subsec. (e) to (g), deleted former Subsec. (i) re coverage maintenance, and made technical changes, effective January 1, 2016; May Sp. Sess. P.A. 16-3 amended Subsec. (a)(4) to replace “Commissioner of Developmental Services” with “Commissioner of Social Services”, effective July 1, 2016; June Sp. Sess. P.A. 17-2 amended Subsecs. (a)(4) and (c) to add references to licensed behavior analyst and delete references to certification of behavior analyst by Behavior Analyst Certification Board, effective July 1, 2018; P.A. 23-204 amended Subsec. (a)(4) by replacing reference to Sec. 17a-215c(l) with reference to Sec. 17a-215c(e), effective July 1, 2023.

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Sec. 38a-514e. Coverage for mental health wellness exams. (a) For the purposes of this section:

(1) “Licensed mental health professional” means: (A) A licensed professional counselor or professional counselor, as defined in section 20-195aa; (B) a person who is under professional supervision, as defined in section 20-195aa; (C) a physician licensed pursuant to chapter 370, who is certified in psychiatry by the American Board of Psychiatry and Neurology; (D) an advanced practice registered nurse licensed pursuant to chapter 378, who is certified as a psychiatric and mental health clinical nurse specialist or nurse practitioner by the American Nurses Credentialing Center; (E) a psychologist licensed pursuant to chapter 383; (F) a marital and family therapist licensed pursuant to chapter 383a; (G) a licensed clinical social worker licensed pursuant to chapter 383b; or (H) an alcohol and drug counselor licensed under chapter 376b; and

(b) (1) Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 and delivered, issued for delivery, renewed, amended or continued in this state on or after January 1, 2023, (A) shall provide coverage for two mental health wellness examinations per year that are performed by a licensed mental health professional, and (B) shall not require prior authorization of such examinations.

(2) The mental health wellness examinations shall be covered with no patient cost sharing.

(c) The provisions of this section shall apply to a high deductible health plan, as that term is used in subsection (f) of section 38a-520, to the maximum extent permitted by federal law, except if such plan is used to establish a medical savings account or an Archer MSA pursuant to Section 220 of the Internal Revenue Code of 1986, as amended from time to time, or any subsequent corresponding Internal Revenue Code of the United States, as amended from time to time, or a health savings account pursuant to Section 223 of said Internal Revenue Code, as amended from time to time, the provisions of this section shall apply to such plan to the maximum extent that (1) is permitted by federal law, and (2) does not disqualify such account for the deduction allowed under said Section 220 or 223, as applicable.

(P.A. 22-47, S. 42; P.A. 23-148, S. 2)

History: P.A. 22-47 effective January 1, 2023; P.A. 23-148 amended Subsec. (a) by deleting former Subdivs. (3) and (4) re definitions of “primary care provider” and “primary care”, amended Subsec. (b)(2) by deleting former Subpara. (A) re health wellness examinations provided by primary care provider, and made technical and conforming changes throughout, effective June 26, 2023.

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Sec. 38a-515. Continuation of coverage of mentally or physically handicapped children. (a) Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state that provides that coverage of a dependent child of an employee or other member of the covered group shall terminate upon attainment of the limiting age for dependent children specified in the policy shall also provide in substance that attainment of the limiting age shall not operate to terminate the coverage of the child if at such date the child is and continues thereafter to be both (1) incapable of self-sustaining employment by reason of mental or physical handicap, as certified by the child's physician, physician assistant or advanced practice registered nurse on a form provided by the insurer, hospital service corporation, medical service corporation or health care center, and (2) chiefly dependent upon such employee or member for support and maintenance.

(b) Proof of the incapacity and dependency shall be furnished to the insurer, hospital service corporation, medical service corporation or health care center by the employee or member within thirty-one days of the child's attainment of the limiting age. The insurer, corporation or center may at any time require proof of the child's continuing incapacity and dependency. After a period of two years has elapsed following the child's attainment of the limiting age the insurer, corporation or center may require periodic proof of the child's continuing incapacity and dependency but in no case more frequently than once every year.

(P.A. 90-243, S. 99; P.A. 11-19, S. 34; P.A. 15-118, S. 13; P.A. 16-39, S. 62; P.A. 17-15, S. 60; P.A. 21-196, S. 68; P.A. 23-127, S. 8.)

History: P.A. 11-19 inserted “renewed, amended or continued” and made technical changes in Subsec. (a), effective January 1, 2012; P.A. 15-118 made technical changes; P.A. 16-39 amended Subsec. (a)(1) by adding reference to advanced practice registered nurse; P.A. 17-15 amended Subsec. (a) to delete “more than one hundred twenty days after July 1, 1971,”; P.A. 21-196 amended Subsec. (a)(1) by adding reference to physician assistant; P.A. 23-127 deleted reference to Sec. 38a-469(6) re accident only coverage.

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Sec. 38a-516. Coverage for newly born children. Notification to insurer. (a) Each group health insurance policy delivered, issued for delivery, renewed, amended or continued in this state providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 for a family member of the insured or subscriber shall, as to such family member's coverage, also provide that the health insurance benefits applicable for children shall be payable with respect to a newly born child of the insured or subscriber from the moment of birth.

(c) If payment of a specific premium fee is required to provide coverage for a child, the policy may require that notification of birth of such newly born child and payment of the required premium or fees shall be furnished to the insurer, hospital service corporation, medical service corporation or health care center not later than ninety-one days after the date of birth in order to continue coverage beyond such period, provided failure to furnish such notice or pay such premium shall not prejudice any claim originating within such period.

(P.A. 90-243, S. 100; P.A. 11-19, S. 36; 11-171, S. 4; P.A. 12-145, S. 13; P.A. 23-127, S. 9; 23-204, S. 224.)

History: P.A. 11-19 inserted “delivered, issued for delivery, renewed, amended or continued in this state” in Subsec. (a), made technical changes in Subsec. (c), and deleted former Subsec. (d) re application of section to policies delivered or issued for delivery on or after October 1, 1974, or amended, effective January 1, 2012; P.A. 11-171 inserted “delivered, issued for delivery, renewed, amended or continued in this state” and made a technical change in Subsec. (a), increased time period for insured to notify insurer of birth of child and pay required premium or fee from 31 days to 61 days after birth and made technical changes in Subsec. (c), and deleted former Subsec. (d) re application of section to policies delivered or issued for delivery on or after October 1, 1974, or amended, effective January 1, 2012; P.A. 12-145 made a technical change in Subsec. (a), effective June 15, 2012; P.A. 23-127 deleted reference to Sec. 38a-469(6) re accident only coverage; P.A. 23-204 made identical change as P.A. 23-127 and amended Subsec. (c) by increasing time period for an insured to notify insurer of the birth of the insured's child and pay required premium or fee from 61 days to 91 days after birth and made technical changes, effective January 1, 2024.

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Sec. 38a-518. Coverage for accidental ingestion or consumption of controlled drugs. Benefits prescribed. No group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6) and (11) of section 38a-469 shall be delivered, issued for delivery or renewed in this state, or amended to substantially alter or change benefits or coverage, on or after July 1, 1975, unless persons covered under such policy will be eligible for benefits for expenses of emergency medical care arising from accidental ingestion or consumption of a controlled drug, as defined by section 21a-240, which are at least equal to the following minimum requirements: (1) In the case of benefits based upon confinement as an inpatient in a hospital, whether or not operated by the state, the period of confinement for which benefits shall be payable shall be at least thirty days in any calendar year. (2) For covered expenses incurred by the insured while other than an inpatient in a hospital, benefits shall be available for such expenses during any calendar year up to a maximum of five hundred dollars. For purposes of this section, the term “covered expenses” means the reasonable charges for treatment deemed necessary under generally accepted medical standards.

(P.A. 90-243, S. 102; P.A. 23-79, S. 48.)

History: P.A. 23-79 made a technical change, effective July 1, 2023.

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Sec. 38a-518a. Mandatory coverage for hypodermic needles and syringes. Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469, delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for hypodermic needles or syringes prescribed by a prescribing practitioner, as defined in section 20-571, for the purpose of administering medications for medical conditions, provided such medications are covered under the policy. Such benefits shall be subject to any policy provisions that apply to other services covered by such policy.

(P.A. 92-185, S. 5, 6; P.A. 95-264, S. 63; P.A. 11-19, S. 38; July Sp. Sess. P.A. 20-4, S. 10; P.A. 21-192, S. 11; P.A. 23-19, S. 15.)

History: P.A. 95-269 changed “licensed” practitioner to “prescribing” practitioner and referenced the definition section (Revisor's note: The reference to “prescribing practitioner, as defined in subdivision (21) of ...” was changed editorially by the Revisors to “prescribing practitioner, as defined in subdivision (22) of ...”); P.A. 11-19 inserted “amended or continued” and made technical changes, effective January 1, 2012; July Sp. Sess. P.A. 20-4 substituted reference to Sec. 20-571(24) for reference to Sec. 20-571(22), effective January 1, 2021; P.A. 21-192 substituted reference to Sec. 20-571(28) for reference to Sec. 20-571(24), effective July 13, 2021; P.A. 23-19 made a conforming change, effective July 1, 2023.

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Sec. 38a-518v. Mandatory coverage for hospice services in the home through a hospice care program to the extent provided for inpatient hospice services. (a) As used in this section, “hospice care program” has the same meaning as provided in section 19a-122e.

(b) Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for hospice services provided to an insured in the home through a hospice care program, to the extent coverage is provided for inpatient hospice services in a hospital. Such coverage shall be subject to the same terms and conditions applicable to all other benefits under such policy.

(c) No such policy shall exclude a hospice service for coverage solely because such service is provided in the home and not at a hospital, provided hospice care in the home is appropriate for the insured.

(d) Nothing in this section shall prohibit or limit a health insurer, health care center, hospital service corporation, medical service corporation or other entity from conducting utilization review for an in-home hospice services, provided such utilization review is conducted in the same manner and uses the same clinical review criteria as a utilization review for the same hospice services provided in a hospital.

(P.A. 23-174, S. 4.)

History: P.A. 23-174 effective January 1, 2024.

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Sec. 38a-536. Mandatory coverage for infertility diagnosis and treatment. Limitations. (a) Subject to the limitations set forth in subsection (b) of this section and except as provided in subsection (c) of this section, each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state on or after January 1, 2018, shall provide coverage for the medically necessary expenses for the diagnosis and treatment of infertility, including, but not limited to, ovulation induction, intrauterine insemination, in-vitro fertilization, uterine embryo lavage, embryo transfer, gamete intra-fallopian transfer, zygote intra-fallopian transfer and low tubal ovum transfer. For purposes of this section, “infertility” means the condition of an individual who is unable to conceive or produce conception or sustain a successful pregnancy during a one-year period or such treatment is medically necessary.

(b) Such policy may:

(1) Limit such coverage for ovulation induction to a lifetime maximum benefit of four cycles;

(2) Limit such coverage for intrauterine insemination to a lifetime maximum benefit of three cycles;

(c) (1) Any insurance company, hospital service corporation, medical service corporation or health care center may issue to a religious employer a group health insurance policy that excludes coverage for methods of diagnosis and treatment of infertility that are contrary to the religious employer's bona fide religious tenets.

(e) As used in this section, “religious employer” means an employer that is a “qualified church-controlled organization”, as defined in 26 USC 3121 or a church-affiliated organization.

(f) Except as provided in subsections (c) to (e), inclusive, of this section, no group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state on or after January 1, 2024, may make any distinction or discrimination between persons on the basis of gender identity or expression, sexual orientation or age with respect to health insurance coverage for the medically necessary expenses for the diagnosis and treatment of infertility, except that such policy may consider age as a factor on the basis of a determination of medical necessity, using professional guidelines published by the American Society for Reproductive Medicine, its successor organization or a comparable organization. For purposes of this subsection, “gender identity or expression” has the same meaning as provided in section 1-1n.

(P.A. 89-120; P.A. 05-196, S. 2; P.A. 15-118, S. 18; P.A. 17-55, S. 2; P.A. 23-127, S. 12.)

History: P.A. 05-196 replaced former provisions with Subsecs. (a) to (e) re required coverage for diagnosis and treatment of infertility, limitations and religious and moral belief exclusions; P.A. 15-118 made technical changes in Subsec. (c); P.A. 17-55 amended Subsec. (a) by replacing “October 1, 2005,” with “January 1, 2018,” replacing “a presumably healthy individual” with “an individual”, and adding “or such treatment is medically necessary”, effective January 1, 2018; P.A. 23-127 amended Subsec. (b) by deleting former Subdiv. (1) re coverage limited until such individual's fortieth birthday, redesignating existing Subdivs. (2) to (6) as Subdivs. (1) to (5), deleting former Subdiv. (7) re coverage limited to individuals who maintained coverage under such policy for 12 months, deleting former Subdiv. (8) re required disclosure to individual's health carrier of previous infertility treatment or procedures under different policy, added Subsec. (f) re prohibiting discrimination or distinction on basis of gender identity or expression, sexual orientation or age with respect to coverage for infertility diagnosis and treatment, except that age may be considered a factor on basis of a determination of medical necessity and made technical and conforming changes in Subsecs. (a) and (b).

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Sec. 38a-544. Prescription drug coverage. Mail order pharmacies. Step therapy use. (a) No insurance company, hospital service corporation, medical service corporation, health care center or other entity delivering, issuing for delivery, renewing, amending or continuing a group health insurance policy or contract that provides coverage for prescription drugs may:

(1) Require any person covered under such policy or contract to obtain prescription drugs from a mail order pharmacy as a condition of obtaining benefits for such drugs; or

(P.A. 89-374; P.A. 14-118, S. 2; P.A. 17-228, S. 2; P.A. 23-204, S. 226.)

History: P.A. 14-118 amended Subsec. (a) to designate existing provision re mail order pharmacy as Subdiv. (1) and add Subdiv. (2) re step therapy, deleted former Subsec. (b) re application of section, added new Subsec. (b) re step therapy override, added Subsec. (c) re effect of section on Secs. 38a-591c to 38a-591g and 38a-518i, and made technical and conforming changes, effective January 1, 2015; P.A. 17-228 amended Subsec. (a) to designate existing provisions re prescribed drug for longer than 60 days as Subpara. (A), and add Subpara. (B) re prescribed drug for cancer treatment in Subdiv. (2), designate existing provisions re deeming step therapy drug regimen clinically ineffective as Subdiv. (3) and amended same to add reference to Subdiv. (2), and make technical changes, effective January 1, 2018; P.A. 23-204 amended Subsec. (a) by substituting 30 days for 60 days in Subdiv. (2)(A), adding Subdiv. (2)(C) re step therapy prescription drug prohibition for treatment of schizophrenia, major depressive disorder and bipolar disorder from January 1, 2024, to January 1, 2027, and made technical and conforming changes, effective January 1, 2024.

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Sec. 38a-549. Coverage for adopted children. (a) Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (10), (11) and (12) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state shall provide coverage for a child legally placed for adoption with an employee or other member of the covered group who is an adoptive parent or a prospective adoptive parent, even though the adoption has not been finalized, provided the child lives in the household of such employee or member and the child is dependent upon such employee or member for support and maintenance.

(c) If payment of a specific premium or subscription fee is required to provide coverage for a child legally placed for adoption with the insured or subscriber who is an adoptive parent or a prospective adoptive parent, the policy may require that notification of acceptance of such child and payment of the required premium or fees be furnished to the insurer, hospital service corporation, medical service corporation or health care center within thirty-one days after the acceptance of such child in order to continue coverage beyond such thirty-one-day period, provided failure to furnish such notice or pay such premium or fees shall not prejudice any claim originating within such thirty-one-day period.

(P.A. 91-97, S. 2; P.A. 02-96, S. 2; P.A. 03-70, S. 2; P.A. 15-118, S. 21; P.A. 23-127, S. 10.)

History: P.A. 02-96 amended Subsec. (a) to substitute “each” for “every” and “amended, renewed or continued in this state” for “amended or renewed in this state on or after October 1, 1991,” and added Subsec. (d) re coverage and prohibited provisions; P.A. 03-70 amended Subsec. (c) to substitute “premium or subscription fee” for “premium fee” and amended Subsec. (d) to add exception re health underwriting if required premium or subscription fee and completed application materials are not provided before expiration of thirty-one-day period; P.A. 15-118 made technical changes in Subsecs. (c) and (d); P.A. 23-127 deleted reference to Sec. 38a-469(6) re accident only coverage.

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PART VII

GRIEVANCES AND EXTERNAL REVIEWS

Sec. 38a-591a. Definitions. As used in this section and sections 38a-591b to 38a-591o, inclusive:

(1) “Adverse determination” means:

(A) The denial, reduction, termination or failure to provide or make payment, in whole or in part, for a benefit under the health carrier's health benefit plan requested by a covered person or a covered person's treating health care professional, based on a determination by a health carrier or its designee utilization review company:

(i) That, based upon the information provided, (I) upon application of any utilization review technique, such benefit does not meet the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness, or (II) is determined to be experimental or investigational;

(ii) Of a covered person's eligibility to participate in the health carrier's health benefit plan; or

(B) Any prospective review, concurrent review or retrospective review determination that denies, reduces or terminates or fails to provide or make payment, in whole or in part, for a benefit under the health carrier's health benefit plan requested by a covered person or a covered person's treating health care professional.

“Adverse determination” includes a rescission of coverage determination for grievance purposes.

(2) “Authorized representative” means:

(A) A person to whom a covered person has given express written consent to represent the covered person for the purposes of this section and sections 38a-591b to 38a-591n, inclusive;

(B) A person authorized by law to provide substituted consent for a covered person;

(C) A family member of the covered person or the covered person's treating health care professional when the covered person is unable to provide consent;

(D) A health care professional when the covered person's health benefit plan requires that a request for a benefit under the plan be initiated by the health care professional; or

(E) In the case of an urgent care request, a health care professional with knowledge of the covered person's medical condition.

(3) “Best evidence” means evidence based on (A) randomized clinical trials, (B) if randomized clinical trials are not available, cohort studies or case-control studies, (C) if such trials and studies are not available, case-series, or (D) if such trials, studies and case-series are not available, expert opinion.

(4) “Case-control study” means a retrospective evaluation of two groups of patients with different outcomes to determine which specific interventions the patients received.

(5) “Case-series” means an evaluation of a series of patients with a particular outcome, without the use of a control group.

(6) “Certification” means a determination by a health carrier or its designee utilization review company that a request for a benefit under the health carrier's health benefit plan has been reviewed and, based on the information provided, satisfies the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care and effectiveness.

(7) “Clinical peer” means a physician or other health care professional who (A) holds a nonrestricted license in a state of the United States and in the same or similar specialty as typically manages the medical condition, procedure or treatment under review, and (B) for a review specified under subparagraph (B) or (C) of subdivision (38) of this section concerning (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 degree with training and clinical experience in the treatment of child and adolescent substance use disorder or child and adolescent mental disorder, as applicable, or (ii) an adult substance use disorder or an adult mental disorder, holds (I) a national board certification in psychiatry, or (II) a doctoral level psychology degree with training and clinical experience in the treatment of adult substance use disorders or adult mental disorders, as applicable.

(8) “Clinical review criteria” means the written screening procedures, decision abstracts, clinical protocols and practice guidelines used by the health carrier to determine the medical necessity and appropriateness of health care services.

(9) “Cohort study” means a prospective evaluation of two groups of patients with only one group of patients receiving a specific intervention or specific interventions.

(10) “Commissioner” means the Insurance Commissioner.

(11) “Concurrent review” means utilization review conducted during a patient's stay or course of treatment in a facility, the office of a health care professional or other inpatient or outpatient health care setting, including home care.

(12) “Covered benefits” or “benefits” means health care services to which a covered person is entitled under the terms of a health benefit plan.

(13) “Covered person” means a policyholder, subscriber, enrollee or other individual participating in a health benefit plan.

(14) “Emergency medical condition” means a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that a prudent layperson with an average knowledge of health and medicine, acting reasonably, would have believed that the absence of immediate medical attention would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person's health or, with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy.

(15) “Emergency services” means, with respect to an emergency medical condition:

(A) A medical screening examination that is within the capability of the emergency department of a hospital, including ancillary services routinely available to the emergency department to evaluate such emergency medical condition; and

(B) Such further medical examination and treatment, to the extent they are within the capability of the staff and facilities available at a hospital, to stabilize a patient.

(16) “Evidence-based standard” means the conscientious, explicit and judicious use of the current best evidence based on an overall systematic review of medical research when making determinations about the care of individual patients.

(17) “Expert opinion” means a belief or an interpretation by specialists with experience in a specific area about the scientific evidence pertaining to a particular service, intervention or therapy.

(18) “Facility” means an institution providing health care services or a health care setting. “Facility” includes a hospital and other licensed inpatient center, ambulatory surgical or treatment center, skilled nursing center, residential treatment center, diagnostic, laboratory and imaging center, and rehabilitation and other therapeutic health care setting.

(19) “Final adverse determination” means an adverse determination (A) that has been upheld by the health carrier at the completion of its internal grievance process, or (B) for which the internal grievance process has been deemed exhausted.

(20) “Grievance” means a written complaint or, if the complaint involves an urgent care request, an oral complaint, submitted by or on behalf of a covered person regarding:

(A) The availability, delivery or quality of health care services, including a complaint regarding an adverse determination made pursuant to utilization review;

(B) Claims payment, handling or reimbursement for health care services; or

(21) (A) “Health benefit plan” means an insurance policy or contract, certificate or agreement offered, delivered, issued for delivery, renewed, amended or continued in this state to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services;

(B) “Health benefit plan” does not include:

(i) Coverage of the type specified in subdivisions (5) to (9), inclusive, (14) and (15) of section 38a-469 or any combination thereof;

(ii) Coverage issued as a supplement to liability insurance;

(iii) Liability insurance, including general liability insurance and automobile liability insurance;

(iv) Workers' compensation insurance;

(v) Automobile medical payment insurance;

(vi) Credit insurance;

(vii) Coverage for on-site medical clinics;

(ix) (I) Limited scope dental or vision benefits, (II) benefits for long-term care, nursing home care, home health care, community-based care or any combination thereof, or (III) other similar, limited benefits specified in regulations issued pursuant to the Health Insurance Portability and Accountability Act of 1996, P.L. 104-191, as amended from time to time, provided any benefits specified in subparagraphs (B)(ix)(I) to (B)(ix)(III), inclusive, of this subdivision are provided under a separate insurance policy, certificate or contract and are not otherwise an integral part of a health benefit plan; or

(x) Coverage of the type specified in subdivisions (3) and (13) of section 38a-469 or other fixed indemnity insurance if (I) they are provided under a separate insurance policy, certificate or contract, (II) there is no coordination between the provision of the benefits and any exclusion of benefits under any group health plan maintained by the same plan sponsor, and (III) the benefits are paid with respect to an event without regard to whether benefits were also provided under any group health plan maintained by the same plan sponsor.

(22) “Health care center” has the same meaning as provided in section 38a-175.

(23) “Health care professional” means a physician or other health care practitioner licensed, accredited or certified to perform specified health care services consistent with state law.

(24) “Health care services” has the same meaning as provided in section 38a-478.

(25) “Health carrier” means an entity subject to the insurance laws and regulations of this state or subject to the jurisdiction of the commissioner, that contracts or offers to contract to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services, including a sickness and accident insurance company, a health care center, a managed care organization, a hospital service corporation, a medical service corporation or any other entity providing a plan of health insurance, health benefits or health care services.

(26) “Health information” means information or data, whether oral or recorded in any form or medium, and personal facts or information about events or relationships that relate to (A) the past, present or future physical, mental, or behavioral health or condition of a covered person or a member of the covered person's family, (B) the provision of health care services to a covered person, or (C) payment for the provision of health care services to a covered person.

(27) “Independent review organization” means an entity that conducts independent external reviews of adverse determinations and final adverse determinations. Such review entities include, but are not limited to, medical peer review organizations, independent utilization review companies, provided such organizations or companies are not related to or associated with any health carrier, and nationally recognized health experts or institutions approved by the Insurance Commissioner.

(28) “Medical or scientific evidence” means evidence found in the following sources:

(A) Peer-reviewed scientific studies published in or accepted for publication by medical journals that meet nationally recognized requirements for scientific manuscripts and that submit most of their published articles for review by experts who are not part of the editorial staff;

(B) Peer-reviewed medical literature, including literature relating to therapies reviewed and approved by a qualified institutional review board, biomedical compendia and other medical literature that meet the criteria of the National Institutes of Health's Library of Medicine for indexing in Index Medicus (Medline) or Elsevier Science for indexing in Excerpta Medicus (EMBASE);

(C) Medical journals recognized by the Secretary of the United States Department of Health and Human Services under Section 1861(t)(2) of the Social Security Act;

(D) The following standard reference compendia: (i) The American Hospital Formulary Service - Drug Information; (ii) Drug Facts and Comparisons; (iii) The American Dental Association's Accepted Dental Therapeutics; and (iv) The United States Pharmacopoeia - Drug Information;

(E) Findings, studies or research conducted by or under the auspices of federal government agencies and nationally recognized federal research institutes, including: (i) The Agency for Healthcare Research and Quality; (ii) the National Institutes of Health; (iii) the National Cancer Institute; (iv) the National Academy of Sciences; (v) the Centers for Medicare and Medicaid Services; (vi) the Food and Drug Administration; and (vii) any national board recognized by the National Institutes of Health for the purpose of evaluating the medical value of health care services; or

(F) Any other findings, studies or research conducted by or under the auspices of a source comparable to those listed in subparagraphs (E)(i) to (E)(v), inclusive, of this subdivision.

(29) “Medical necessity” has the same meaning as provided in sections 38a-482a and 38a-513c.

(30) “Participating provider” means a health care professional who, under a contract with the health carrier, its contractor or subcontractor, has agreed to provide health care services to covered persons, with an expectation of receiving payment or reimbursement directly or indirectly from the health carrier, other than coinsurance, copayments or deductibles.

(31) “Person” has the same meaning as provided in section 38a-1.

(32) “Prospective review” means utilization review conducted prior to an admission or the provision of a health care service or a course of treatment, in accordance with a health carrier's requirement that such service or treatment be approved, in whole or in part, prior to such service's or treatment's provision.

(33) “Protected health information” means health information (A) that identifies an individual who is the subject of the information, or (B) for which there is a reasonable basis to believe that such information could be used to identify such individual.

(34) “Randomized clinical trial” means a controlled, prospective study of patients that have been randomized into an experimental group and a control group at the beginning of the study, with only the experimental group of patients receiving a specific intervention, and that includes study of the groups for variables and anticipated outcomes over time.

(35) “Rescission” means a cancellation or discontinuance of coverage under a health benefit plan that has a retroactive effect. “Rescission” does not include a cancellation or discontinuance of coverage under a health benefit plan if (A) such cancellation or discontinuance has a prospective effect only, or (B) such cancellation or discontinuance is effective retroactively to the extent it is attributable to the covered person's failure to timely pay required premiums or contributions towards the cost of such coverage.

(36) “Retrospective review” means any review of a request for a benefit that is not a prospective review or concurrent review. “Retrospective review” does not include a review of a request that is limited to the veracity of documentation or the accuracy of coding.

(37) “Stabilize” means, with respect to an emergency medical condition, that (A) no material deterioration of such condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual from a facility, or (B) with respect to a pregnant woman, the woman has delivered, including the placenta.

(38) “Urgent care request” means a request for a health care service or course of treatment (A) for which the time period for making a non-urgent care request determination (i) could seriously jeopardize the life or health of the covered person or the ability of the covered person to regain maximum function, or (ii) in the opinion of a health care professional with knowledge of the covered person's medical condition, would subject the covered person to severe pain that cannot be adequately managed without the health care service or treatment being requested, or (B) for a substance use disorder, as described in section 17a-458, or for a co-occurring mental disorder, or (C) for a mental disorder requiring (i) inpatient services, (ii) partial hospitalization, as defined in section 38a-496, (iii) residential treatment, or (iv) intensive outpatient services necessary to keep a covered person from requiring an inpatient setting.

(39) “Utilization review” means the use of a set of formal techniques designed to monitor the use of, or evaluate the medical necessity, appropriateness, efficacy or efficiency of, health care services, health care procedures or health care settings. Such techniques may include the monitoring of or evaluation of (A) health care services performed or provided in an outpatient setting, (B) the formal process for determining, prior to discharge from a facility, the coordination and management of the care that a patient receives following discharge from a facility, (C) opportunities or requirements to obtain a clinical evaluation by a health care professional other than the one originally making a recommendation for a proposed health care service, (D) coordinated sets of activities conducted for individual patient management of serious, complicated, protracted or other health conditions, or (E) prospective review, concurrent review, retrospective review or certification.

(40) “Utilization review company” means an entity that conducts utilization review.

(P.A. 11-58, S. 54; P.A. 12-102, S. 6; P.A. 13-3, S. 70, 71; P.A. 14-40, S. 1; P.A. 23-204, S. 220.)

History: P.A. 11-58 effective July 1, 2011; P.A. 12-102 replaced references to Sec. 38a-591m with references to Sec. 38a-591n in introductory provision and Subdiv. (2)(A); P.A. 13-3 redefined “clinical peer” in Subdiv. (7) and “urgent care request” in Subdiv. (38) by adding provisions re substance use and mental disorders; P.A. 14-40 amended Subdiv. (7) to redefine “clinical peer”, effective May 28, 2014; P.A. 23-204 amended introductory language to add reference to Sec. 38a-591o.

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Sec. 38a-591c. Utilization review criteria and procedures. (a)(1) Each health carrier shall contract with (A) health care professionals to administer such health carrier's utilization review program, and (B) clinical peers to evaluate the clinical appropriateness of an adverse determination.

(2) (A) Each utilization review program shall use documented clinical review criteria that are based on sound clinical evidence and are evaluated periodically by the health carrier's organizational mechanism specified in subparagraph (F) of subdivision (2) of subsection (c) of section 38a-591b to assure such program's ongoing effectiveness.

(B) Except as provided in subdivisions (3), (4) and (5) of this subsection, a health carrier may develop its own clinical review criteria or it may purchase or license clinical review criteria from qualified vendors approved by the commissioner, provided such clinical review criteria conform to the requirements of subparagraph (A) of this subdivision.

(C) Each health carrier shall (i) post on its Internet web site (I) any clinical review criteria it uses, and (II) links to any rule, guideline, protocol or other similar criterion a health carrier may rely upon to make an adverse determination as described in subparagraph (F) of subdivision (1) of subsection (e) of section 38a-591d, and (ii) make its clinical review criteria available upon request to authorized government agencies.

(3) For any utilization review for the treatment of a substance use disorder, as described in section 17a-458, the clinical review criteria used shall be: (A) The most recent edition of the American Society of Addiction Medicine Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions; or (B) clinical review criteria that the health carrier demonstrates to the Insurance Department is consistent with the most recent edition of the American Society of Addiction Medicine Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions, except that nothing in this subdivision shall prohibit a health carrier from developing its own clinical review criteria or purchasing or licensing additional clinical review criteria from qualified vendors approved by the commissioner, to address advancements in technology or types of care for the treatment of a substance use disorder, that are not covered in the most recent edition of the American Society of Addiction Medicine Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. 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.

(4) For any utilization review for the treatment of a child or adolescent mental disorder, the clinical review criteria used shall be: (A) The most recent guidelines of the American Academy of Child and Adolescent Psychiatry's Child and Adolescent Service Intensity Instrument; 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 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 Standards and Guidelines of the Association for 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 in the 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;

(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.

(c) If a health carrier delegates any utilization review activities to a utilization review company, the health carrier shall maintain adequate oversight, which shall include (1) a written description of the utilization review company's activities and responsibilities, including such company's reporting requirements, (2) evidence of the health carrier's formal approval of the utilization review company program, and (3) a process by which the health carrier shall evaluate the utilization review company's performance.

(d) When conducting utilization review, the health carrier shall (1) collect only the information necessary, including pertinent clinical information, to make the utilization review or benefit determination, and (2) ensure that such review is conducted in a manner to ensure the independence and impartiality of the individual or individuals involved in making the utilization review or benefit determination. No health carrier shall make decisions regarding the hiring, compensation, termination, promotion or other similar matters of such individual or individuals based on the likelihood that the individual or individuals will support the denial of benefits.

(e) Each participating provider shall utilize a health carrier's electronic program that securely accommodates the processing of utilization review requests, provided such participating provider's failure to utilize such health carrier's electronic program shall not contribute to an adverse determination.

(P.A. 11-58, S. 56; P.A. 13-3, S. 72; 13-134, S. 22; P.A. 14-40, S. 2; June Sp. Sess. P.A. 15-5, S. 352; P.A. 16-175, S. 1; P.A. 23-204, S. 230.)

History: P.A. 11-58 effective July 1, 2011; P.A. 13-3 amended Subsec. (a) by adding provision requiring clinical peers to conduct utilization reviews in Subdiv. (1) and adding Subdivs. (3), (4) and (5) re clinical review criteria for substance use and mental disorders, amended Subsec. (b)(1) by designating existing provision as Subpara. (A) and adding Subpara. (B) re clinical peers designated to conduct utilization reviews, and amended Subsec. (d) by replacing “individual or individuals” with “clinical peer or peers”; P.A. 13-134 made a technical change in Subsec. (a)(1); P.A. 14-40 amended Subsec. (a)(1) to delete provision re clinical peers to conduct utilization reviews, and amended Subsecs. (b)(1) and (d) to replace references to clinical peer or peers with references to individual or individuals, effective May 28, 2014; June Sp. Sess. P.A. 15-5 amended Subsec. (a)(3) to replace “American Society of Addiction Medicine's Patient Placement Criteria” with “American Society of Addiction Medicine Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions”, effective July 1, 2015; P.A. 16-175 amended Subsec. (a) by substantially revising provisions re clinical review criteria that health carriers' utilization review programs may use, including adding provisions re health carrier to post on Internet web site any clinical review criteria they use and links to any rule, guideline, protocol or other similar criterion relied upon to make adverse determination in Subdiv. (1)(C) and adding provisions re health carrier's development of clinical review criteria or purchase or licensing additional clinical review criteria from qualified vendors and deleting provisions re health carrier that uses clinical review criteria to create and maintain document on Internet web site in Subdivs. (3) to (5), effective January 1, 2017; P.A. 23-204 added Subsec. (e) re participating providers required to use health carrier's electronic program for utilization review requests, effective January 1, 2024.

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Sec. 38a-591d. Utilization review and benefit determinations. Urgent care requests. Information provided in notice of adverse determination. (a)(1) Each health carrier shall maintain written procedures for (A) utilization review and benefit determinations, (B) expedited utilization review and benefit determinations with respect to prospective urgent care requests and concurrent review urgent care requests, and (C) notifying covered persons or covered persons' authorized representatives of such review and benefit determinations. Each health carrier shall make such review and benefit determinations within the specified time periods under this section.

(2) In determining whether a benefit request shall be considered an urgent care request, an individual acting on behalf of a health carrier shall apply the judgment of a prudent layperson who possesses an average knowledge of health and medicine, except that any benefit request (A) determined to be an urgent care request by a health care professional with knowledge of the covered person's medical condition, or (B) specified under subparagraph (B) or (C) of subdivision (38) of section 38a-591a shall be deemed an urgent care request.

(3) (A) At the time a health carrier notifies a covered person, a covered person's authorized representative or a covered person's health care professional of an initial adverse determination that was based, in whole or in part, on medical necessity, of a concurrent or prospective utilization review or of a benefit request, the health carrier shall notify the covered person's health care professional (i) of the opportunity for a conference as provided in subparagraph (B) of this subdivision, and (ii) that such conference shall not be considered a grievance of such initial adverse determination as long as a grievance has not been filed as set forth in subparagraph (B) of this subdivision.

(B) After a health carrier notifies a covered person, a covered person's authorized representative or a covered person's health care professional of an initial adverse determination that was based, in whole or in part, on medical necessity, of a concurrent or prospective utilization review or of a benefit request, the health carrier shall offer a covered person's health care professional the opportunity to confer, at the request of the covered person's health care professional, with a clinical peer of such health carrier, provided such covered person, covered person's authorized representative or covered person's health care professional has not filed a grievance of such initial adverse determination prior to such conference. Such conference shall not be considered a grievance of such initial adverse determination.

(b) With respect to a nonurgent care request:

(1) (A) For a prospective or concurrent review request, a health carrier shall make a determination within a reasonable period of time appropriate to the covered person's medical condition, but not later than seven calendar days after the date the health carrier receives such request, and shall notify the covered person and, if applicable, the covered person's authorized representative of such determination, whether or not the carrier certifies the provision of the benefit.

(B) If the review under subparagraph (A) of this subdivision is a review of a grievance involving 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.

(2) For a retrospective review request, a health carrier shall make a determination within a reasonable period of time, but not later than thirty calendar days after the date the health carrier receives such request.

(3) (A) The time period specified in subdivision (1) of this subsection may be extended once by the health carrier for up to five calendar days, and the time period specified in subdivision (2) of this subsection may be extended once by the health carrier for up to fifteen calendar days, provided the health carrier:

(i) Determines that an extension is necessary due to circumstances beyond the health carrier's control; and

(ii) Notifies the covered person and, if applicable, the covered person's authorized representative prior to the expiration of the initial time period, of the circumstances requiring the extension of time and the date by which the health carrier expects to make a determination.

(B) Notwithstanding the provisions of subparagraph (A) of subdivision (3) of this subsection, the time period specified in subdivision (1) of this subsection may be extended once by the health carrier for up to fifteen calendar days, provided the covered person's health care professional notifies the health carrier that the service will not be performed for at least three months from the date such health carrier received the request.

(4) (A) If the extension pursuant to subdivision (3) of this subsection is necessary due to the failure of the covered person or the covered person's authorized representative to provide information necessary to make a determination on the request, the health carrier shall:

(i) Specifically describe in the notice of extension the required information necessary to complete the request; and

(ii) Provide the covered person and, if applicable, the covered person's authorized representative with not less than forty-five calendar days after the date of receipt of the notice to provide the specified information.

(B) If the covered person or the covered person's authorized representative fails to submit the specified information before the end of the period of the extension, the health carrier may deny certification of the benefit requested.

(1) (A) Unless the covered person or the covered person's authorized representative has failed to provide information necessary for the health carrier to make a determination and except as specified under subparagraph (B) of this subdivision, the health carrier shall make a determination as soon as possible, taking into account the covered person's medical condition, but not later than twenty-four hours after the health carrier receives such request, provided, if the urgent care request is a concurrent review request to extend a course of treatment beyond the initial period of time or the number of treatments, such request is made not less than twenty-four hours prior to the expiration of the prescribed period of time or number of treatments.

(B) Unless the covered person or the covered person's authorized representative has failed to provide information necessary for the health carrier to make a determination, for an urgent care request specified under subparagraph (B) or (C) of subdivision (38) of section 38a-591a, the health carrier shall make a determination as soon as possible, taking into account the covered person's medical condition, but not later than twenty-four hours after the health carrier receives such request, provided, if the urgent care request is a concurrent review request to extend a course of treatment beyond the initial period of time or the number of treatments, such request is made not less than twenty-four hours prior to the expiration of the prescribed period of time or number of treatments.

(2) (A) If the covered person or the covered person's authorized representative has failed to provide information necessary for the health carrier to make a determination, the health carrier shall notify the covered person or the covered person's representative, as applicable, as soon as possible, but not later than twenty-four hours after the health carrier receives such request.

(B) The health carrier shall provide the covered person or the covered person's authorized representative, as applicable, a reasonable period of time to submit the specified information, taking into account the covered person's medical condition, but not less than forty-eight hours after notifying the covered person or the covered person's authorized representative, as applicable.

(3) The health carrier shall notify the covered person and, if applicable, the covered person's authorized representative of its determination as soon as possible, but not later than forty-eight hours after the earlier of (A) the date on which the covered person and the covered person's authorized representative, as applicable, provides the specified information to the health carrier, or (B) the date on which the specified information was to have been submitted.

(d) (1) Whenever a health carrier receives a review request from a covered person or a covered person's authorized representative that fails to meet the health carrier's filing procedures, the health carrier shall notify the covered person and, if applicable, the covered person's authorized representative of such failure not later than five calendar days after the health carrier receives such request, except that for an urgent care request, the health carrier shall notify the covered person and, if applicable, the covered person's authorized representative of such failure not later than twenty-four hours after the health carrier receives such request. For a nonurgent prospective or concurrent review request, each health carrier shall acknowledge receipt of each such request as soon as practicable, but not later than twenty-four hours after the health carrier receives such request, except that such health carrier shall respond in less time if such a response is required by applicable federal law.

(2) If the health carrier provides such notice orally, the health carrier shall provide confirmation in writing to the covered person and the covered person's health care professional of record not later than three calendar days after providing the oral notice. No health carrier shall require a health care professional or hospital to submit additional information that was not reasonably available to such health care professional or hospital at the time that such health care professional or hospital filed the prospective or concurrent review request with such health carrier.

(e) Each health carrier shall provide promptly to a covered person and, if applicable, the covered person's authorized representative a notice of an adverse determination.

(1) Such notice may be provided in writing or by electronic means and shall set forth, in a manner calculated to be understood by the covered person or the covered person's authorized representative:

(A) Information sufficient to identify the benefit request or claim involved, including the date of service, if applicable, the health care professional and the claim amount;

(B) The specific reason or reasons for the adverse determination, including, upon request, a listing of the relevant clinical review criteria, including professional criteria and medical or scientific evidence and a description of the health carrier's standard, if any, that were used in reaching the denial;

(D) A description of any additional material or information necessary for the covered person to perfect the benefit request or claim, including an explanation of why the material or information is necessary to perfect the request or claim;

(E) A description of the health carrier's internal grievance process that includes (i) the health carrier's expedited review procedures, (ii) any time limits applicable to such process or procedures, (iii) the contact information for the organizational unit designated to coordinate the review on behalf of the health carrier, and (iv) a statement that the covered person or, if applicable, the covered person's authorized representative is entitled, pursuant to the requirements of the health carrier's internal grievance process, to receive from the health carrier, free of charge upon request, reasonable access to and copies of all documents, records, communications and other information and evidence regarding the covered person's benefit request;

(F) (i) (I) A copy of the specific rule, guideline, protocol or other similar criterion the health carrier relied upon to make the adverse determination, or (II) a statement that a specific rule, guideline, protocol or other similar criterion of the health carrier was relied upon to make the adverse determination and that a copy of such rule, guideline, protocol or other similar criterion will be provided to the covered person free of charge upon request, with instructions for requesting such copy, and (ii) the links to such rule, guideline, protocol or other similar criterion on such health carrier's Internet web site;

(G) If the adverse determination is based on medical necessity or an experimental or investigational treatment or similar exclusion or limit, the written statement of the scientific or clinical rationale for the adverse determination and (i) an explanation of the scientific or clinical rationale used to make the determination that applies the terms of the health benefit plan to the covered person's medical circumstances, or (ii) a statement that an explanation will be provided to the covered person free of charge upon request, and instructions for requesting a copy of such explanation;

(H) A statement explaining the right of the covered person to contact the commissioner's office or the Office of the Healthcare Advocate at any time for assistance or, upon completion of the health carrier's internal grievance process, to file a civil action in a court of competent jurisdiction. Such statement shall include the contact information for said offices; and

(I) A statement, expressed in language approved by the Healthcare Advocate and prominently displayed on the first page or cover sheet of the notice using a call-out box and large or bold text, that if the covered person or the covered person's authorized representative chooses to file a grievance of an adverse determination, (i) such appeals are sometimes successful, (ii) such covered person or covered person's authorized representative may benefit from free assistance from the Office of the Healthcare Advocate, which can assist such covered person or covered person's authorized representative with the filing of a grievance pursuant to 42 USC 300gg-93, as amended from time to time, (iii) such covered person or covered person's authorized representative is entitled and encouraged to submit supporting documentation for the health carrier's consideration during the review of an adverse determination, including narratives from such covered person or covered person's authorized representative and letters and treatment notes from such covered person's health care professional, and (iv) such covered person or covered person's authorized representative has the right to ask such covered person's health care professional for such letters or treatment notes.

(2) Upon request pursuant to subparagraph (E) of subdivision (1) of this subsection, the health carrier shall provide such copies in accordance with subsection (a) of section 38a-591n.

(f) If the adverse determination is a rescission, the health carrier shall include with the advance notice of the application for rescission required to be sent to the covered person, a written statement that includes:

(1) Clear identification of the alleged fraudulent act, practice or omission or the intentional misrepresentation of material fact;

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

(3) A disclosure that the covered person or the covered person's authorized representative may file immediately, without waiting for the date such advance notice of the proposed rescission ends, a grievance with the health carrier to request a review of the adverse determination to rescind coverage, pursuant to sections 38a-591e and 38a-591f;

(4) A description of the health carrier's grievance procedures established under sections 38a-591e and 38a-591f, including any time limits applicable to those procedures; and

(5) The date such advance notice of the proposed rescission ends and the date back to which the coverage will be retroactively rescinded.

(g) (1) Whenever a health carrier fails to strictly adhere to the requirements of this section with respect to making utilization review and benefit determinations of a benefit request or claim, the covered person shall be deemed to have exhausted the internal grievance process of such health carrier and may file a request for an external review in accordance with the provisions of section 38a-591g, regardless of whether the health carrier asserts it substantially complied with the requirements of this section or that any error it committed was de minimis.

(2) A covered person who has exhausted the internal grievance process of a health carrier may, in addition to filing a request for an external review, pursue any available remedies under state or federal law on the basis that the health carrier failed to provide a reasonable internal grievance process that would yield a decision on the merits of the claim.

(P.A. 11-58, S. 57; P.A. 12-102, S. 1; P.A. 13-3, S. 73; P.A. 14-40, S. 3; P.A. 15-118, S. 54; 15-139, S. 1; P.A. 16-175, S. 2; P.A. 19-117, S. 241; P.A. 22-47, S. 71; P.A. 23-204, S. 222.)

History: P.A. 11-58 effective July 1, 2011; P.A. 12-102 amended Subsec. (e) to designate provisions re adverse determination notice as new Subdiv. (1), redesignate existing Subdivs. (1) to (8) as Subparas. (A) to (H) and make conforming changes, add “communications” and “evidence regarding” re benefit request in redesignated Subdiv. (1)(E), and add new Subdiv. (2) re health carrier obligation to provide copies in accordance with Sec. 38a-591n(a); P.A. 13-3 amended Subsec. (a) by adding reference to Sec. 38a-591a(38)(B) or (C) in Subdiv. (2) and adding Subdiv. (3) re conference opportunity offer, amended Subsec. (b) by designating existing Subdiv. (1) as Subdiv. (1)(A) and adding Subdiv. (1)(B) re continuation of treatment during review of a grievance, amended Subsec. (c) by designating existing Subdiv. (1) as Subdiv. (1)(A) and making a conforming change therein, and adding Subdiv. (1)(B) re 24-hour determination period for urgent care requests for substance use or mental disorder treatment, and amended Subsec. (e)(1) by adding clinical review criteria to information required to be provided to a covered person with an adverse determination notice in Subpara. (B), deleting provision re submission of written comments, documents, records and other material in Subpara. (E), adding provision re Internet web site links in Subpara. (F), and adding Subpara. (I) re statement specifying additional assistance information to be provided to a covered person with an adverse determination notice; P.A. 14-40 amended Subsec. (e)(1)(I) to delete reference to Division of Consumer Affairs within Insurance Department, effective May 28, 2014; P.A. 15-118 made a technical change in Subsec. (e)(1)(H); P.A. 15-139 amended Subsec. (a)(3) by adding Subpara. (A) re notification of clinical peer conference, designating existing provisions re clinical peer conference as Subpara. (B) and amending same to change such conference from optional to mandatory at the request of covered person's health care professional and make conforming changes; P.A. 16-175 amended Subsec. (e)(1)(F) by replacing “If the adverse determination is based on a health carrier's internal rule, guideline, protocol or other similar criterion, (i) the specific rule, guideline, protocol or other similar criterion, or (ii)(I)” with “(i)(I) A copy of the specific rule, guideline, protocol or other similar criterion the health carrier relied upon to make the adverse determination, or (II)”, designating existing provisions re statement and Internet links as clauses (i)(II) and (ii), respectively, deleting provision re notice of adverse determination involving treatment of substance use disorder or mental disorder, and making conforming changes, effective January 1, 2017; P.A. 19-117 amended Subsec. (c)(1)(A) by substituting “forty-eight hours” for “seventy-two hours” and adding “or seventy-two hours after such health carrier receives such request if any portion of such forty-eight-hour period falls on a weekend”, effective January 1, 2020; P.A. 22-47 amended Subsec. (e)(1)(I) re statement regarding the grievance procedure must be approved by the Healthcare Advocate and be prominently displayed, effective January 1, 2023; P.A. 23-204 amended Subsec. (b)(1)(A) by substituting 7 calendar days for 15 calendar days for nonurgent prospective and concurrent review request determinations, designated existing Subsec. (b)(3) as new Subsec. (b)(3)(A) and amended same re extension of nonurgent prospective and concurrent review requests changed from 15 calendar days to 5 calendar days and extension of retrospective review request determinations, added new Subsec. (b)(3)(B) re time period may be extended once by the health carrier for up to 15 calendar days, provided service is not performed for at least 3 months from date such health carrier received the request, redesignated existing Subparas. (A) and (B) as clauses (i) and (ii), amended Subsec. (c) by substituting 24 hours for 48 hours for urgent care requests and deleting “or seventy-two hours after such health carrier receives such request if any portion of such forty-eight-hour period falls on a weekend”, amended Subsec. (d)(1) by adding provision re health carrier acknowledge receipt of nonurgent care prospective and concurrent review requests not later than 24 hours after such health carrier receives such request, amended Subsec. (d)(2) by substituting 3 calendar days for 5 calendar days and prohibiting a health carrier from requiring a health care professional or hospital to submit additional information not reasonably available at time request was submitted and made technical and conforming changes, effective January 1, 2024.

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Sec. 38a-591o. (Note: This section is effective January 1, 2025.) Restrictions applicable to prospective or concurrent review of certain recurring prescription drugs. Exceptions. (a) As used in this section:

(1) “Brand name drug” means a drug that is produced or distributed in accordance with an original new drug application approved under 21 USC 355, as amended from time to time, but does not include a generic drug as defined in 42 CFR 447.502, as amended from time to time;

(2) “Generic drug” means (A) a prescription drug product that is marketed or distributed in accordance with an abbreviated new drug application approved under 21 USC 355, as amended from time to time, (B) a generic drug as defined in 42 CFR 447.502, as amended from time to time, or (C) a drug that entered the market before calendar year 1962 that was not originally marketed under a new prescription drug product application; and

(3) “Third-party administrator” has the same meaning as provided in section 38a-720.

(b) No health carrier shall require a prospective or concurrent review of a recurring prescription drug to directly treat any autoimmune disorder, multiple sclerosis or cancer after such health carrier has certified such prescription drug through utilization review. Nothing in this section shall require a health carrier to cover: (1) Any prescription drug to treat any autoimmune disorder, multiple sclerosis or cancer if the terms of coverage completely exclude such prescription drug from the policy's covered benefits; (2) a brand name drug when an equivalent generic drug is available; (3) a prescription drug that was certified through prospective or concurrent review (A) by such covered person's previous health carrier, or (B) under a previous employer's fully insured health plan administered by a third-party administrator that provided coverage to such covered person.

(P.A. 23-204, S. 221.)

History: P.A. 23-204 effective January 1, 2025.

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