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Senate Bill No. 1297

Public Act No. 05-97

AN ACT CONCERNING MANAGED CARE GRIEVANCE PROCEDURES.

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

Section 1. Section 38a-478m of the general statutes is repealed and the following is substituted in lieu thereof (Effective October 1, 2005):

(a) Each managed care organization shall establish and maintain an internal grievance procedure to assure that enrollees may seek a review of any grievance that may arise from a managed care organization's action or inaction, other than action or inaction based on utilization review, and obtain a timely resolution of any such grievance. Such grievance procedure shall comply with the following requirements:

(1) Enrollees shall be informed of the grievance procedure at the time of initial enrollment and at not less than annual intervals thereafter, which notification may be met by inclusion in an enrollment agreement or update. [Enrollees] Each enrollee and the enrollee's provider shall also be informed of the grievance procedure when a decision has been made not to certify an admission, service or extension of stay ordered by the provider.

(2) Notices to enrollees and providers describing the grievance procedure shall explain: (A) The process for filing a grievance with the managed care organization, which may be communicated orally, electronically or in writing; (B) that the enrollee, or a person acting on behalf of an enrollee, including the enrollee's health care provider, may make a request for review of a grievance; and (C) the time periods within which the managed care organization must resolve the grievance.

(b) All reviews conducted under this section shall be resolved not later than sixty days from the date the enrollee or person acting on behalf of the enrollee commences the complaint, unless an extension is requested by the enrollee or person acting on behalf of the enrollee.

(c) A managed care organization that fails to provide notice of the resolution of a complaint within the time provided in subsection (b) of this section shall be fined twenty-five dollars for each failure to provide notice. Any fines collected under this section shall be paid to the Insurance Commissioner and deposited in the Insurance Fund established in section 38a-52a. The amount of such fines shall be allocated to the Office of Managed Care Ombudsman for the purposes set forth in section 38a-1041.

Sec. 2. Section 38a-816 of the general statutes is amended by adding subdivision (22) as follows (Effective October 1, 2005):

(NEW) (22) Any violation of section 38a-478m, as amended by this act.

Approved June 7, 2005