Bill Text: CT SB00375 | 2016 | General Assembly | Comm Sub
Bill Title: An Act Authorizing Multistate Health Care Centers In Connecticut And Eliminating A Health Carrier Utilization Review Report Filing Requirement.
Spectrum: Committee Bill
Status: (Introduced - Dead) 2016-05-03 - Senate Recommitted to Insurance and Real Estate [SB00375 Detail]
Download: Connecticut-2016-SB00375-Comm_Sub.html
General Assembly |
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February Session, 2016 |
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AN ACT AUTHORIZING MULTISTATE HEALTH CARE CENTERS IN CONNECTICUT AND ELIMINATING A HEALTH CARRIER UTILIZATION REVIEW REPORT FILING REQUIREMENT.
Be it enacted by the Senate and House of Representatives in General Assembly convened:
Section 1. Section 38a-175 of the 2016 supplement to the general statutes is repealed and the following is substituted in lieu thereof (Effective July 1, 2016):
As used in this section and sections [38a-175] 38a-176 to 38a-194, inclusive:
(1) "Healing arts" means the professions and occupations licensed under the provisions of chapters 370, 372, 373, 375, 378, 379, 380, 381, 383 and 400j.
(2) "Carrier" means a health care center, insurer, hospital service corporation, medical service corporation or other entity responsible for the payment of benefits or provision of services under a group contract.
(3) "Commissioner" means the Insurance Commissioner, except when explicitly stated otherwise.
(4) "Evidence of coverage" means a statement of essential features and services of the health care center coverage [which] that is given to the subscriber by the health care center or by the group contract holder.
(5) "Federal Health Maintenance Organization Act" means Title XIII of the Public Health Service Act, 42 USC Subchapter XI, as [from time to time] amended from time to time, or any successor thereto relating to qualified health maintenance organizations.
(6) "Group contract" means a contract for health care services [which] that by its terms limits eligibility to members of a specified group. The group contract may include coverage for dependents.
(7) "Group contract holder" means the person to which a group contract has been issued.
(8) "Health care" includes, but shall not be limited to, the following: (A) Medical, surgical and dental care provided through licensed practitioners, including any supporting and ancillary personnel, services and supplies; (B) physical therapy service provided through licensed physical therapists upon the prescription of a physician; (C) psychological examinations provided by registered psychologists; (D) optometric service provided by licensed optometrists; (E) hospital service, both inpatient and outpatient; (F) convalescent institution care and nursing home care; (G) nursing service provided by a registered nurse or by a licensed practical nurse; (H) home care service of all types required for the health of a person; (I) rehabilitation service required or desirable for the health of a person; (J) preventive medical services of all and any types; (K) furnishing necessary appliances, drugs, medicines and supplies; (L) educational services for the health and well-being of a person; (M) ambulance service; and (N) any other care, service or treatment related to the prevention or treatment of disease, the correction of defects and the maintenance of the physical and mental well-being of human beings. Any diagnosis and treatment of diseases of human beings required for health care as defined in this section, if rendered, shall be under the supervision and control of the providers.
(9) "Health care center" means: [either: (A) A person, including a profit or a nonprofit corporation organized under the laws of this state] (A) any organization governed by sections 38a-175 to 38a-192, inclusive, and licensed or authorized by the commissioner pursuant to section 38a-41 or 38a-41a, for the purpose of carrying out the activities and purposes set forth in subsection (b) of section 38a-176, at the expense of the health care center, including the providing of health care [, as herein defined,] to members of the community, including subscribers to one or more plans under an agreement entitling such subscribers to health care in consideration of a basic advance or periodic charge and shall include a health maintenance organization, or (B) a line of business conducted by an organization that is formed [,] pursuant to the laws of this state for the purposes of, but not limited to, carrying out the activities and purposes set forth in subsection (b) of section 38a-176.
(10) "Individual contract" means a contract for health care services issued to and covering an individual. The individual contract may include dependents of the subscriber.
(11) "Individual practice association" means a partnership, corporation, association [,] or other legal entity [which] that has entered into a services arrangement with health care professionals licensed in this state to provide services to enrollees of a health care center.
(12) "Insolvent" or "insolvency" means, with respect to an organization, that the organization has been declared insolvent and placed under an order of liquidation by a court of competent jurisdiction.
(13) "Net worth" means the excess of total admitted assets over total liabilities, but the liabilities shall not include fully subordinated debt, as [defined] that term is used in section 38a-193.
(14) "Member" or "enrollee" means an individual who is enrolled in a health care center.
(15) "Person" means an individual, corporation, limited liability company, partnership, association, trust or any other legal entity.
(16) "Uncovered expenditures" means the cost of health care services that are covered by a health care center, for which an enrollee would also be liable in the event of the health care center's insolvency, and for which no alternative arrangements have been made that are acceptable to the commissioner. [Uncovered expenditures shall] "Uncovered expenditures" does not include expenditures for services when a provider has agreed not to bill the enrollee even though the provider is not paid by the health care center or for services that are guaranteed, insured or assumed by a person other than the health care center.
(17) "Enrolled population" means a group of persons, defined as to probable age, sex and family composition, [which] that receives health care from a health care center in consideration of a basic advance or periodic charge.
(18) "Participating provider" means a provider who, under an express or implied contract with the health care center or with its contractor or subcontractor, has agreed to provide health care services to enrollees with an expectation of receiving payment, other than copayment or deductible, directly or indirectly from the health care center.
(19) "Provider" means any licensed health care professional or facility, including individual practice associations.
(20) "Subscriber" means an individual whose employment or other status, except family dependency, is the basis for eligibility for enrollment in the health care center, or in the case of an individual contract, the person in whose name the contract is issued.
Sec. 2. Section 38a-178 of the general statutes is repealed and the following is substituted in lieu thereof (Effective July 1, 2016):
Persons desiring to form a health care center may organize under the general law of the state governing corporations, partnerships, associations or trusts, [but] subject to the following provisions: (1) The certificate of incorporation or other organizational document of each such organization shall have endorsed thereon or attached thereto the consent of the commissioner if [he] the commissioner finds the same to be in accordance with the provisions of sections 38a-175 to 38a-192, inclusive, as amended by this act; and (2) the certificate or other document shall include a statement of the area in which the health care center will operate and the services to be rendered by such organization within this state and in other jurisdictions in which the health care center may be authorized to do business.
Sec. 3. Section 38a-179 of the general statutes is repealed and the following is substituted in lieu thereof (Effective July 1, 2016):
(a) If [the] a domestic health care center is organized as a nonprofit, nonstock corporation, the care, control and disposition of the property and funds of each such corporation and the general management of its affairs shall be vested in a board of directors. Each such corporation shall have the power to adopt bylaws for the governing of its affairs, which bylaws shall prescribe the number of directors, their term of office and the manner of their election, subject to the provisions of sections 38a-175 to 38a-192, inclusive, as amended by this act. The bylaws may be adopted and repealed or amended by the affirmative vote of two-thirds of all the directors at any meeting of the board of directors duly held upon at least ten days' notice, provided notice of such meeting shall specify the proposed action concerning the bylaws to be taken at such meeting. The bylaws of the corporation shall provide that the board of directors shall include representation from persons engaged in the healing arts and from persons who are eligible to receive health care from the corporation, subject to the following provisions: (1) One-quarter of the board of directors shall be persons engaged in the different fields in the healing arts at least two of whom shall be a physician and a dentist; (2) one-quarter of the board of directors shall be subscribers who are eligible to receive health care from the health care center, but no such representative need be seated until the first annual meeting following the approval by the commissioner of the initial agreement or agreements to be offered by the corporation, and there shall be only one representative from any group covered by a group service agreement.
(b) If [the] a domestic health care center is not organized as a nonprofit, nonstock corporation, management of its affairs shall be in accordance with other applicable laws of the state, provided [that the] such health care center shall establish and maintain a mechanism to afford its members an opportunity to participate in matters of policy and operation such as an advisory panel, advisory referenda on major policy decisions or other similar mechanisms.
Sec. 4. Section 38a-186 of the general statutes is repealed and the following is substituted in lieu thereof (Effective July 1, 2016):
(a) In the event of the dissolution, liquidation or termination of the corporate existence of a domestic health care center [which] that is organized as a nonprofit, nonstock corporation, no part of the property or assets of the health care center shall inure to the benefit of any director, officer, subscriber or employee of the corporation, each of whom by holding such position shall be deemed to have waived and relinquished all rights conferred by statute or otherwise upon subscribers of a corporation without capital stock to share in such assets upon dissolution, liquidation or termination. After the payment of all lawful claims against the corporation, all its remaining assets shall be devoted permanently and exclusively to the purposes for which the corporation is formed, or paid over to an organization organized and operated exclusively for charitable, educational and scientific purposes, and in such amount and proportions, as the board of directors in its discretion shall determine.
(b) No person may, with respect to a domestic health care center, (1) make a tender for or a request or invitation for tenders of, or enter into an agreement to exchange securities for or acquire in the open market or otherwise, any voting security of [a] such health care center, (2) enter into any other agreement if, after the consummation [thereof, that] of such agreement, such person would, directly or indirectly, or by conversion or by exercise of any right to acquire, be in control of such health care center, or (3) enter into an agreement to merge or consolidate with or otherwise to acquire control of [a] such health care center, unless, at the time any offer, request or invitation is made or any agreement is entered into, or prior to the acquisition of the securities if no offer or agreement is involved, the person has [filed with the Insurance Commissioner and has mailed or delivered to the health care center, such information as is required by the commissioner and the offer, request, invitation, agreement or acquisition has been approved by the commissioner] complied with the provisions of section 38a-130.
Sec. 5. Section 38a-188 of the 2016 supplement to the general statutes is repealed and the following is substituted in lieu thereof (Effective July 1, 2016):
(a) Each health care center governed by sections 38a-175 to 38a-192, inclusive, as amended by this act, shall be exempt from the provisions of the general statutes relating to insurance in the conduct of its operations under said sections and in such other activities as do constitute the business of insurance, unless expressly included therein, and except for the following: Sections 38a-11, 38a-14a, 38a-17, 38a-51, 38a-52, as amended by this act, 38a-56, 38a-57, 38a-58a, 38a-129 to 38a-140, inclusive, 38a-147 and 38a-815 to 38a-819, inclusive, provided a health care center shall not be deemed in violation of sections 38a-815 to 38a-819, inclusive, solely by virtue of such health care center selectively contracting with certain providers in one or more specialties, and sections 38a-80, 38a-492b, 38a-518b, 38a-543, 38a-702j, 38a-703 to 38a-718, inclusive, 38a-731 to 38a-735, inclusive, 38a-741 to 38a-745, inclusive, 38a-769, 38a-770, 38a-772 to 38a-776, inclusive, 38a-786, 38a-790, 38a-792 and 38a-794, provided a health care center organized as a nonprofit, nonstock corporation shall be exempt from sections 38a-146, 38a-702j, 38a-703 to 38a-718, inclusive, 38a-731 to 38a-735, inclusive, 38a-741 to 38a-745, inclusive, 38a-769, 38a-770, 38a-772 to 38a-776, inclusive, 38a-786, 38a-790, 38a-792 and 38a-794. If a health care center is operated as a line of business, the foregoing provisions shall, where possible, be applied only to that line of business and not to the organization as a whole.
(b) The commissioner may adopt regulations, in accordance with chapter 54, stating the circumstances under which the resources of a person [which] that controls a health care center, or operates a health care center as a line of business will be considered in evaluating the financial condition of a health care center. Such regulations, if adopted, shall require as a condition to the consideration of the resources of such person that controls a health care center, or operates a health care center as a line of business to provide satisfactory assurances to the commissioner that such person will assume the financial obligations of the health care center. During the period prior to the effective date of regulations issued under this section, the commissioner shall, upon request, consider the resources of a person that controls a health care center, or operates a health care center as a line of business, if the commissioner receives satisfactory assurances from such person that it will assume the financial obligations of the health care center and determines that such person meets such other requirements as the commissioner determines are necessary.
(c) A health care center organized as a nonprofit, nonstock corporation shall be exempt from the sales and use tax and all property of each such corporation shall be exempt from state, district and municipal taxes. Each corporation governed by sections 38a-175 to 38a-192, inclusive, as amended by this act, shall be subject to the provisions of sections 38a-903 to 38a-961, inclusive. Nothing in this section shall be construed to override contractual and delivery system arrangements governing a health care center's provider relationships.
Sec. 6. Subdivision (9) of section 12-201 of the 2016 supplement to the general statutes is repealed and the following is substituted in lieu thereof (Effective July 1, 2016):
(9) "Direct subscriber charges" means all charges made by a domestic health care center [, as defined in section 38a-175,] to subscribers, [as defined in section 38a-175,] by whomever paid. As used in this subdivision, "health care center" and "subscriber" have the same meanings as provided in section 38a-175, as amended by this act;
Sec. 7. Subsection (a) of section 12-202a of the 2016 supplement to the general statutes is repealed and the following is substituted in lieu thereof (Effective July 1, 2016):
(a) Each domestic health care center [, as defined in section 38a-175,] that is governed by sections 38a-175 to 38a-192, inclusive, as amended by this act, shall pay a tax to the Commissioner of Revenue Services for the calendar year commencing on January 1, 1995, and annually thereafter, at the rate of one and three-quarters per cent of the total net direct subscriber charges received by such health care center during each such calendar year on any new or renewal contract or policy approved by the Insurance Commissioner under section 38a-183. Such payment shall be in addition to any other payment required under section 38a-48.
Sec. 8. Subsections (c) to (e), inclusive, of section 12-217t of the 2016 supplement to the general statutes are repealed and the following is substituted in lieu thereof (Effective July 1, 2016):
(c) The credit provided for by this section shall be allowed for any taxes owed on the grand list of October 1, 1994, and each grand list annually thereafter or included in the list prescribed under section 12-80a for such grand list. Such credits shall first be used by the taxpayer against the corporation business tax under this chapter, if any, and then may be used against any tax paid by the taxpayer under the provisions of chapter 207, 208a, 209, 210, 211 or 212 or the tax imposed upon a domestic health care center under section 12-202a, as amended by this act. The amount of credits allowable under this section in any tax year against the taxes imposed by chapter 207, 208, 208a, 209, 210, 211 or 212 or against the tax imposed on domestic health care centers, under the provisions of section 12-202a, as amended by this act, shall be allowable only after all other credits allowable against such taxes for such tax year have been applied.
(d) In the case of leased electronic data processing equipment, the lessee, not the lessor, shall be entitled to claim the credit allowed pursuant to this section if the lease by its terms or operation imposes on the lessee the cost of the personal property taxes on such equipment, provided the lessor and lessee may elect, in writing, that the lessor may claim the credit provided by this section. The lessor shall provide a copy of such election to the Commissioner of Revenue Services, upon the request of said commissioner.
(e) In the case of taxpayers filing a combined unitary tax return pursuant to section 12-222, the credit provided by this section shall be allowed on a combined basis, such that the amount of personal property taxes paid by such taxpayers with respect to such equipment may be claimed as a tax credit against the combined unitary tax liability of such taxpayers as determined under this chapter. Credits available to taxpayers which are subject to tax under this chapter but not subject to tax under chapter 207, 208a, 209, 210, 211 or 212 or the tax imposed on domestic health care centers under the provisions of section 12-202a, as amended by this act, shall be used prior to credits of companies included in such combined unitary tax return which are also subject to tax under said chapter 207, 208a, 209, 210, 211 or 212 or the tax imposed upon domestic health centers pursuant to the provisions of section 12-202a, as amended by this act.
Sec. 9. Subparagraph (A) of subdivision (2) of subsection (b) of section 19a-7j of the general statutes is repealed and the following is substituted in lieu thereof (Effective July 1, 2016):
(2) (A) Each domestic insurer or domestic health care center doing health insurance business in this state shall annually pay to the Insurance Commissioner, for deposit in the Insurance Fund established under section 38a-52a, a health and welfare fee assessed by the Insurance Commissioner pursuant to this section.
Sec. 10. Subdivision (2) of subsection (b) of section 19a-7p of the 2016 supplement to the general statutes is repealed and the following is substituted in lieu thereof (Effective July 1, 2016):
(2) Each domestic insurer or domestic health care center doing health insurance business in this state shall annually pay to the Insurance Commissioner, for deposit in the Insurance Fund established under section 38a-52a, a public health fee assessed by the Insurance Commissioner pursuant to this section.
Sec. 11. Subsection (h) of section 38a-14 of the 2016 supplement to the general statutes is repealed and the following is substituted in lieu thereof (Effective July 1, 2016):
(h) The commissioner shall, at least once in every five years, visit and examine the affairs of each domestic insurance company, domestic health care center, domestic fraternal benefit society, and foreign and alien insurance company doing business in this state. Notwithstanding subdivision (1) of subsection (c) of this section, no domestic insurance company or other domestic entity subject to examination under this section shall pay as costs associated with the examination the salaries, fringe benefits, traveling and maintenance expenses of examining personnel of the Insurance Department engaged in such examination if such domestic company or domestic entity is otherwise liable to assessment levied under section 38a-47, except that a domestic insurance company or other domestic entity shall pay the traveling and maintenance expenses of examining personnel of the Insurance Department when such company or entity is examined outside the state.
Sec. 12. Section 38a-43 of the general statutes is repealed and the following is substituted in lieu thereof (Effective July 1, 2016):
Whenever it appears to the commissioner that permission to transact business within any state of the United States or within any foreign country has been refused to any domestic insurance company or domestic health care center after (1) a certificate of the solvency and good management of such company or health care center has been issued to it by the commissioner, and [after] (2) such company or health care center has complied with any reasonable laws of such state or foreign country requiring deposits of money or securities with the government of such state or country, the commissioner may immediately cancel the authority of each company or health care center organized under the laws of such state or foreign government and licensed to do business in this state and may refuse a certificate of authority to each such company or health care center thereafter applying for authority to do business in this state, until the commissioner's certificate has been recognized by the government of such state or country.
Sec. 13. Section 38a-52 of the general statutes is repealed and the following is substituted in lieu thereof (Effective July 1, 2016):
Any (1) domestic insurance company or other domestic entity aggrieved because of any assessment levied under section 38a-48, (2) fraternal benefit society or foreign or alien insurance company or other entity aggrieved because of any assessment levied under the provisions of sections 38a-49 to 38a-51, inclusive, or (3) domestic insurer, domestic health care center, third-party administrator licensed pursuant to section 38a-720a or exempt insurer, as defined in subdivision (1) of subsection (b) of section 19a-7j, aggrieved because of any assessment levied under said section 19a-7j, may, within one month from the time provided for the payment of such assessment, appeal therefrom to the superior court for the judicial district of New Britain, which appeal shall be accompanied by a citation to the commissioner to appear before said court. Such citation shall be signed by the same authority, and such appeal shall be returnable at the same time and served and returned in the same manner, as is required in case of a summons in a civil action. The authority issuing the citation shall take from the appellant a bond or recognizance to the state, with surety to prosecute the appeal to effect and to comply with the orders and decrees of the court in the premises. Such appeals shall be preferred cases, to be heard, unless cause appears to the contrary, at the first session, by the court or by a committee appointed by the court. Said court may grant such relief as may be equitable, and, if such assessment has been paid prior to the granting of such relief, may order the Treasurer to pay the amount of such relief, with interest at the rate of six per cent per annum, to the aggrieved company. If the appeal has been taken without probable cause, the court may tax double or triple costs, as the case demands; and, upon all such appeals which may be denied, costs may be taxed against the appellant at the discretion of the court, but no costs shall be taxed against the state.
Sec. 14. Section 38a-53 of the 2016 supplement to the general statutes is repealed and the following is substituted in lieu thereof (Effective July 1, 2016):
(a) (1) Each domestic insurance company or domestic health care center shall, annually, on or before the first day of March, submit to the commissioner, and electronically to the National Association of Insurance Commissioners, a true and complete report, signed and sworn to by its president or a vice president, and secretary or an assistant secretary, of its financial condition on the thirty-first day of December next preceding, prepared in accordance with the National Association of Insurance Commissioners annual statement instructions handbook and following those accounting procedures and practices prescribed by the National Association of Insurance Commissioners accounting practices and procedures manual, subject to any deviations in form and detail as may be prescribed by the commissioner. An electronically filed report in accordance with section 38a-53a that is timely submitted to the National Association of Insurance Commissioners shall not exempt a domestic insurance company or domestic health care center from timely filing a true and complete paper copy with the commissioner.
(2) Each accredited reinsurer, as defined in subdivision (1) of subsection (c) of section 38a-85, and assuming insurance company, as provided in section 38a-85, shall file an annual report in accordance with the provisions of section 38a-85.
(b) Each foreign insurance company doing business in this state shall, annually, on or before the first day of March, submit to the commissioner, by electronically filing with the National Association of Insurance Commissioners, a true and complete report, signed and sworn to by its president or a vice president, and secretary or an assistant secretary, of its financial condition on the thirty-first day of December next preceding, prepared in accordance with the National Association of Insurance Commissioners annual statement instructions handbook and following those accounting procedures and practices prescribed by the National Association of Insurance Commissioners accounting practices and procedures manual, subject to any deviations in form and detail as may be prescribed by the commissioner. An electronically filed report in accordance with section 38a-53a that is timely submitted to the National Association of Commissioners shall be deemed to have been submitted to the commissioner in accordance with this section.
(c) In addition to such annual report, the commissioner, when the commissioner deems it necessary, may require any insurance company or health care center doing business in this state to file financial statements on a quarterly basis. An electronically filed true and complete report filed in accordance with section 38a-53a that is timely filed with the National Association of Insurance Commissioners shall be deemed to have been submitted to the commissioner in accordance with the provisions of this section.
(d) In addition to such annual report and the quarterly report required under subsection (c) of this section, the commissioner, whenever the commissioner determines that more frequent reports are required because of certain factors or trends affecting companies writing a particular class or classes of business or because of changes in the company's management or financial or operating condition, may require any insurance company or health care center doing business in this state to file financial statements on other than an annual or quarterly basis.
(e) Any insurance company or health care center doing business in this state that fails to file any report or statement required under this section shall pay a late filing fee of one hundred seventy-five dollars per day for each day from the due date of such report or statement to the date of filing. The commissioner may extend the due date of any report or statement required under this section (1) if the insurance company or health care center cannot file such report or statement because the governor of such company's or center's state of domicile has proclaimed a state of emergency in such state and such state of emergency impairs the company's or center's ability to file the report or statement, (2) if the insurance regulatory official of the state of domicile of a foreign insurance company has permitted such company to file such report or statement late, or (3) for a domestic insurance company or a domestic health care center, for good cause shown.
(f) Each insurance company or health care center doing business in this state shall include in all reports required to be filed with the commissioner under this section a certification by an actuary or reserve specialist of all reserve liabilities prepared in accordance with regulations that shall be adopted by the commissioner in accordance with chapter 54. The regulations shall: (1) Specify the contents and scope of the certification; (2) provide for the availability to the commissioner of the workpapers of the actuary or loss reserve specialist; and (3) provide for granting companies or centers exemptions from compliance with the requirements of this subsection. The commissioner shall maintain, as confidential, all workpapers of the actuary or loss reserve specialist and the actuarial report and actuarial opinion summary provided in support of the certification. Such workpapers, reports and summaries shall not be subject to subpoena or disclosure under the Freedom of Information Act, as defined in section 1-200.
Sec. 15. Subsection (a) of section 38a-54 of the general statutes is repealed and the following is substituted in lieu thereof (Effective July 1, 2016):
(a) Each domestic insurance company, domestic health care center or domestic fraternal benefit society doing business in this state shall have an annual audit conducted by an independent certified public accountant and shall annually file an audited financial report with the commissioner, and electronically to the National Association of Insurance Commissioners on or before the first day of June for the year ending the preceding December thirty-first. An electronically filed true and complete report timely submitted to the National Association of Insurance Commissioners does not exempt a domestic insurance company or a domestic health care center from timely filing a true and complete paper copy to the commissioner.
Sec. 16. Section 38a-55 of the general statutes is repealed and the following is substituted in lieu thereof (Effective July 1, 2016):
(a) No domestic insurer, domestic health care center or domestic fraternal benefit society may pledge, hypothecate or otherwise encumber its assets to secure the debt, guaranty or obligations of any other person without the prior written consent of the Insurance Commissioner. This prohibition shall not apply to obligations of the insurer under surety bonds or insurance contracts issued in the regular course of business.
(b) (1) No domestic insurer, domestic health care center or domestic fraternal benefit society may, without the prior written consent of the Insurance Commissioner, pledge, hypothecate or otherwise encumber its assets to secure its own debt, guaranty or obligations if the amount of the assets pledged, hypothecated or otherwise encumbered, when the pledge, hypothecation or encumbrance is made, together with the aggregate amount of assets pledged, hypothecated or encumbered to secure all such debts, guarantees and obligations, exceeds the lesser of five per cent of admitted assets or twenty-five per cent of surplus as regards policyholders as reported in its last financial statement filed with the commissioner pursuant to section 38a-53, as amended by this act, or 38a-614.
(2) Nothing in this subsection shall be construed as prohibiting a domestic insurer, domestic health care center or domestic fraternal benefit society from pledging, hypothecating or encumbering any assets in connection with: (A) Transactions in the ordinary course of business, including, but not limited to: (i) Complying with any statutory requirement, (ii) reinsurance transactions otherwise in compliance with applicable statutory requirements, or (iii) investments or investment practices otherwise in compliance with applicable statutory requirements, including, but not limited to, securities lending, repurchase transactions, reverse repurchase transactions, swap, futures and options transactions, and any other transactions which are not prohibited by the investment law and regulations of this state; (B) transactions subject to the provisions of sections 38a-129 to 38a-140, inclusive; or (C) any other transaction deemed excluded by the Insurance Commissioner. Assets pledged, hypothecated or encumbered pursuant to subparagraph (A), (B) or (C) of this subdivision shall not be charged against the limits set forth in subdivision (1) of this subsection.
(3) In the case of a domestic life insurance company, the provisions of this subsection shall apply to a separate account only to the extent that reserves for guarantees with respect to (A) benefits guaranteed as to dollar amount and duration or (B) funds guaranteed as to principal amount or stated rate of interest are held in a separate account in accordance with subdivision (3) of subsection (a) of section 38a-433.
Sec. 17. Section 38a-59 of the general statutes is repealed and the following is substituted in lieu thereof (Effective July 1, 2016):
An amendment to the certificate of incorporation of a domestic insurance company or a domestic health care center with capital stock that changes the name of the company or health care center shall not become effective until approved by the Insurance Commissioner after reasonable notice and a public hearing, if such notice and hearing are deemed by the commissioner to be in the public interest. A certificate of amendment conforming to the requirements of section 33-800 shall be filed in the office of the Insurance Commissioner before any amendment to the certificate of incorporation of a domestic insurance company or a domestic health care center with capital stock becomes effective.
Sec. 18. Section 38a-591b of the 2016 supplement to the general statutes, as amended by section 10 of public act 15-146, is repealed and the following is substituted in lieu thereof (Effective July 1, 2016):
(a) Sections 38a-591a to 38a-591n, inclusive, shall apply to (1) any health carrier offering a health benefit plan and that provides or performs utilization review including prospective, concurrent or retrospective review benefit determinations, and (2) any utilization review company or designee of a health carrier that performs utilization review on the health carrier's behalf, including prospective, concurrent or retrospective review benefit determinations.
(b) Each health carrier shall be responsible for monitoring all utilization review program activities carried out by or on behalf of such health carrier. Such health carrier shall comply with the provisions of sections 38a-591a to 38a-591n, inclusive, and any regulations adopted thereunder, and shall be responsible for ensuring that any utilization review company or other entity such health carrier contracts with to perform utilization review complies with said sections and regulations. Each health carrier shall ensure that appropriate personnel have operational responsibility for the activities of the health carrier's utilization review program.
(c) (1) A health carrier that requires utilization review of a benefit request under a health benefit plan shall implement a utilization review program and develop a written document that describes all utilization review activities and procedures, whether or not delegated, for (A) the filing of benefit requests, (B) the notification to covered persons of utilization review and benefit determinations, and (C) the review of adverse determinations and grievances in accordance with sections 38a-591e, as amended by this act, and 38a-591f.
(2) Such document shall describe the following:
(A) Procedures to evaluate the medical necessity, appropriateness, health care setting, level of care or effectiveness of health care services;
(B) Data sources and clinical review criteria used in making determinations;
(C) Procedures to ensure consistent application of clinical review criteria and compatible determinations;
(D) Data collection processes and analytical methods used to assess utilization of health care services;
(E) Provisions to ensure the confidentiality of clinical, proprietary and protected health information;
(F) The health carrier's organizational mechanism, such as a utilization review committee or quality assurance or other committee, that periodically assesses the health carrier's utilization review program and reports to the health carrier's governing body; and
(G) The health carrier's staff position that is responsible for the day-to-day management of the utilization review program.
(d) Each health carrier shall:
(1) Include in the insurance policy, certificate of coverage or handbook provided to covered persons a clear and comprehensive description of:
(A) Its utilization review and benefit determination procedures;
(B) Its grievance procedures, including the grievance procedures for requesting a review of an adverse determination;
(C) A description of the external review procedures set forth in section 38a-591g, in a format prescribed by the commissioner and including a statement that discloses that:
(i) A covered person may file a request for an external review of an adverse determination or a final adverse determination with the commissioner and that such review is available when the adverse determination or the final adverse determination involves an issue of medical necessity, appropriateness, health care setting, level of care or effectiveness. Such disclosure shall include the contact information of the commissioner; and
(ii) When filing a request for an external review of an adverse determination or a final adverse determination, the covered person shall be required to authorize the release of any medical records that may be required to be reviewed for the purpose of making a decision on such request;
(D) A statement of the rights and responsibilities of covered persons with respect to each of the procedures under subparagraphs (A) to (C), inclusive, of this subdivision. Such statement shall include a disclosure that a covered person has the right to contact the commissioner's office or the Office of Healthcare Advocate at any time for assistance and shall include the contact information for said offices;
(E) A description of what constitutes a surprise bill, as defined in subsection (a) of section 38a-477aa;
(2) Inform its covered persons, at the time of initial enrollment and at least annually thereafter, of its grievance procedures. This requirement may be fulfilled by including such procedures in an enrollment agreement or update to such agreement;
(3) Inform a covered person or the covered person's health care professional, as applicable, at the time the covered person or the covered person's health care professional requests a prospective or concurrent review: (A) The network status under such covered person's health benefit plan of the health care professional who will be providing the health care service or course of treatment; (B) an estimate of the amount the health carrier will reimburse such health care professional for such service or treatment; and (C) how such amount compares to the usual, customary and reasonable charge, as determined by the Centers for Medicare and Medicaid Services, for such service or treatment;
(4) Inform a covered person and the covered person's health care professional of the health carrier's grievance procedures whenever the health carrier denies certification of a benefit requested by a covered person's health care professional;
(5) Prominently post on its Internet web site the description required under subparagraph (E) of subdivision (1) of this subsection;
(6) Include in materials intended for prospective covered persons a summary of its utilization review and benefit determination procedures;
(7) Print on its membership or identification cards a toll-free telephone number for utilization review and benefit determinations;
(8) Maintain records of all benefit requests, claims and notices associated with utilization review and benefit determinations made in accordance with section 38a-591d for not less than six years after such requests, claims and notices were made. Each health carrier shall make such records available for examination by the commissioner and appropriate federal oversight agencies upon request; and
(9) Maintain records in accordance with section 38a-591h of all grievances received. Each health carrier shall make such records available for examination by covered persons, to the extent such records are permitted to be disclosed by law, the commissioner and appropriate federal oversight agencies upon request.
[(e) (1) On or before March first annually, each health carrier shall file with the commissioner:
(A) A summary report of its utilization review program activities in the calendar year immediately preceding; and
(B) A report that includes for each type of health benefit plan offered by the health carrier:
(i) A certificate of compliance certifying that the utilization review program of the health carrier or its designee complies with all applicable state and federal laws concerning confidentiality and reporting requirements;
(ii) The number of covered lives;
(iii) The total number of grievances received;
(iv) The number of grievances resolved at each level, if applicable, and their resolution;
(v) The number of grievances appealed to the commissioner of which the health carrier has been informed;
(vi) The number of grievances referred to alternative dispute resolution procedures or resulting in litigation; and
(vii) A synopsis of actions being taken to correct any problems identified.
(2) The commissioner shall adopt regulations, in accordance with chapter 54, to establish the form and content of the reports specified in subdivision (1) of this subsection.]
Sec. 19. Subdivision (3) of subsection (a) of section 38a-591e of the general statutes is repealed and the following is substituted in lieu thereof (Effective July 1, 2016):
(3) In addition to a copy of such procedures, each health carrier shall file annually with the commissioner, [as part of its annual report required under subsection (e) of section 38a-591b] in a form prescribed by the commissioner, a certificate of compliance stating that the health carrier has established and maintains grievance procedures for each of its health benefit plans that are fully compliant with the provisions of sections 38a-591a to 38a-591n, inclusive.
Sec. 20. Section 38a-591h of the general statutes is repealed and the following is substituted in lieu thereof (Effective July 1, 2016):
(a) (1) Each health carrier shall maintain written records to document all grievances of adverse determinations it receives, including the notices and claims associated with such grievances, during a calendar year.
(2) (A) Each health carrier shall maintain such records for not less than six years after the notice of an adverse determination that is the subject of a grievance was provided to a covered person or the covered person's authorized representative, as applicable, under section 38a-591d.
(B) The health carrier shall make such records available for examination by covered persons, to the extent such records are permitted to be disclosed by law, the commissioner and appropriate federal oversight agencies upon request. Such records shall be maintained in a manner that is reasonably clear and accessible to the commissioner.
(b) For each grievance the record shall contain, at a minimum, the following information: (1) A general description of the reason for the grievance; (2) the date the health carrier received the grievance; (3) the date of each review or, if applicable, review meeting of the grievance; (4) the resolution at each level of the grievance, if applicable; (5) the date of resolution at each such level, if applicable; and (6) the name of the covered person for whom the grievance was filed.
[(c) Each health carrier shall submit a report annually to the commissioner, in accordance with section 38a-591b, of the grievances it received.]
[(d)] (c) (1) Each health carrier shall maintain written records of all requests for external reviews, whether such requests are for standard or expedited external reviews, that such health carrier receives notice of from the commissioner in a calendar year. The health carrier shall maintain such records in the aggregate by state where the covered person requesting such review resides and by each type of health benefit plan offered by the health carrier, and shall submit a report to the commissioner upon request, in a format prescribed by the commissioner.
(2) Such report shall include, in the aggregate by state where the covered person requesting such review resides and by each type of health benefit plan:
(A) The total number of requests for an external review, whether such requests were for a standard or expedited external review;
(B) From the total number of such requests reported under subparagraph (A) of this subdivision, the number of requests determined eligible for a full external review, whether such requests were for a standard or expedited external review; and
(C) Any other information the commissioner may request or require.
(3) The health carrier shall retain the written records required pursuant to subdivision (1) of this subsection for not less than six years after the request for an external review or an expedited external review was received.
This act shall take effect as follows and shall amend the following sections: | ||
Section 1 |
July 1, 2016 |
38a-175 |
Sec. 2 |
July 1, 2016 |
38a-178 |
Sec. 3 |
July 1, 2016 |
38a-179 |
Sec. 4 |
July 1, 2016 |
38a-186 |
Sec. 5 |
July 1, 2016 |
38a-188 |
Sec. 6 |
July 1, 2016 |
12-201(9) |
Sec. 7 |
July 1, 2016 |
12-202a(a) |
Sec. 8 |
July 1, 2016 |
12-217t(c) to (e) |
Sec. 9 |
July 1, 2016 |
19a-7j(b)(2)(A) |
Sec. 10 |
July 1, 2016 |
19a-7p(b)(2) |
Sec. 11 |
July 1, 2016 |
38a-14(h) |
Sec. 12 |
July 1, 2016 |
38a-43 |
Sec. 13 |
July 1, 2016 |
38a-52 |
Sec. 14 |
July 1, 2016 |
38a-53 |
Sec. 15 |
July 1, 2016 |
38a-54(a) |
Sec. 16 |
July 1, 2016 |
38a-55 |
Sec. 17 |
July 1, 2016 |
38a-59 |
Sec. 18 |
July 1, 2016 |
38a-591b |
Sec. 19 |
July 1, 2016 |
38a-591e(a)(3) |
Sec. 20 |
July 1, 2016 |
38a-591h |
Statement of Legislative Commissioners:
In Sections 8(c) and 18(c)(1), ", as amended by this act" was added and in Section 1(12), (13) and (16), technical changes were added, for consistency with standard drafting conventions.
INS |
Joint Favorable Subst. -LCO |