Bill Text: CT SB00383 | 2018 | General Assembly | Introduced

---

Bill Title: An Act Concerning Alternative Treatment Options.

Spectrum: Committee Bill

Status: (Introduced - Dead) 2018-03-02 - Public Hearing 03/06 [SB00383 Detail]

Download: Connecticut-2018-SB00383-Introduced.html

---

General Assembly		Raised Bill No. 383
February Session, 2018		LCO No. 1833
		*01833_______INS*
Referred to Committee on INSURANCE AND REAL ESTATE
Introduced by:
(INS)

AN ACT CONCERNING ALTERNATIVE TREATMENT OPTIONS.

Be it enacted by the Senate and House of Representatives in General Assembly convened:

Section 1. Subsection (d) of section 38a-472f of the 2018 supplement to the general statutes is repealed and the following is substituted in lieu thereof (Effective January 1, 2019):

(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, and shall not deny such request unless the health carrier provides a written notice to the covered person (A) confirming that a participating provider is available to provide the covered benefit to the covered person, (B) containing the name, address and telephone number of the participating provider, and (C) certifying that the participating provider is able to provide the covered benefit to the covered person without unreasonable travel or delay and at an in-network level of cost-sharing. 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.

Sec. 2. Subsection (e) of section 38a-591d of the general statutes is repealed and the following is substituted in lieu thereof (Effective January 1, 2019):

(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;

(C) Reference to the specific health benefit plan provisions on which the determination is based;

(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 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; [.] and

(J) If the adverse determination is based on medical necessity, a description of alternative treatments or services that would satisfy the health carrier's medical necessity criteria and the name, address and telephone number of each in-network health care provider licensed to provide such treatments or services who is available to provide such treatments or services to the covered person without unreasonable travel or delay at an in-network level of cost-sharing.

(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.

This act shall take effect as follows and shall amend the following sections:
Section 1	January 1, 2019	38a-472f(d)
Sec. 2	January 1, 2019	38a-591d(e)

Statement of Purpose:

To require health carriers to provide additional information to insureds (1) regarding the availability of health care services from nonparticipating providers, and (2) following an adverse determination.

[Proposed deletions are enclosed in brackets. Proposed additions are indicated by underline, except that when the entire text of a bill or resolution or a section of a bill or resolution is new, it is not underlined.]