OLR Bill Analysis

sSB 638 (File 119, as amended by Senate “A”)*

AN ACT CONCERNING HEALTH INSURANCE COVERAGE FOR COLONOSCOPIES.

SUMMARY:

This bill prohibits certain health insurance policies from imposing a coinsurance, copayment, deductible, or other out-of-pocket expense for a second or subsequent colonoscopy a physician orders for an insured person in a policy year. It specifies that this prohibition does not apply to a high-deductible health plan designed to be compatible with federally qualified health savings accounts.

By law, a policy must cover colorectal cancer screening, including (1) an annual fecal occult blood test and (2) colonoscopy, flexible sigmoidoscopy, or radiologic imaging, in accordance with recommendations the American College of Gastroenterology, in consultation with the American Cancer Society, establishes based on age, family history, and frequency. Benefits are subject to the same terms and conditions that apply to others under the policy.

The bill also requires an insurer or other entity writing group health insurance in Connecticut to offer a “reasonably designed” health behavior wellness, maintenance, or improvement program. The program must give participants one or more of the following: (1) a reward; (2) health spending account contribution; (3) premium reduction; or (4) reduced copayment, coinsurance, or deductible. The bill prohibits the value of any reward or incentive from exceeding 20% of “paid premiums” and requires them to comply with federal non-discrimination requirements (see BACKGROUND).

The bill requires the insurance commissioner, in consultation with the public health commissioner, to adopt regulations to establish criteria for health behavior wellness, maintenance, or improvement programs and procedures for approving them. It requires an insured person or plan enrollee to give the insurer or entity proof of program participation in a manner the insurance commissioner approves.

The bill exempts a reward or incentive allowed under its provisions from the laws prohibiting insurance rebates. It also makes technical and conforming changes.

*Senate Amendment “A” adds the health behavior wellness, maintenance, and improvement program provisions.

EFFECTIVE DATE: January 1, 2010

COLONOSCOPY COVERAGE APPLICABILITY

The bill applies to individual and group health insurance policies delivered, issued, renewed, amended, or continued in Connecticut that cover (1) basic hospital expenses; (2) basic medical-surgical expenses; (3) major medical expenses; and (4) hospital or medical services, including coverage under an HMO plan.

Due to federal law (ERISA), state insurance benefit mandates do not apply to self-insured benefit plans.

BACKGROUND

Federal Rule for Wellness Programs

HIPAA prohibits discrimination based on health status. Related U. S. Department of Labor (DOL) rules prohibit a wellness program from offering rewards if a person has to attain some health status in order to receive it. A program can encourage healthy habits through an incentive, such as program cost reimbursement, but reimbursement cannot be conditioned on a person actually changing his or her habits.

According to DOL, an employer's wellness program complies with federal nondiscrimination requirements if it is open to all similarly situated individuals and, if a reward is offered, it is not conditioned on a person satisfying a health factor-related standard, unless the program meets the following five requirements:

1. a premium discount that does not exceed 20% of the total cost of employee-only coverage (or 20% of the cost of coverage if dependents can participate in the program);

2. the program is reasonably designed to promote health and prevent disease;

3. people eligible for the program have an opportunity to qualify for the reward at least once a year;

4. the program, to accommodate people for whom it is unreasonably difficult to quit using tobacco products because of an addiction, provides a reasonable alternative standard (such as a discount if the person attends educational classes or tries a nicotine patch); and

5. plan material describing a premium discount also describes the reasonable alternative standard available to qualify for the lower premium.

COMMITTEE ACTION

Insurance and Real Estate Committee

Joint Favorable

Yea

13

Nay

6

(03/03/2009)

Appropriations Committee

Joint Favorable

Yea

43

Nay

10

(04/27/2009)