OLR Bill Analysis

sHB 5021 (as amended by House "A")*

AN ACT EXPANDING HEALTH INSURANCE COVERAGE FOR OSTOMY SUPPLIES.

SUMMARY:

The bill requires certain health insurance policies to include (1) coverage for prosthetic devices, and repairs and replacements to them, subject to specified conditions; (2) specified coverage for human leukocyte antigen testing; (3) a “reasonably designed” health behavior wellness, maintenance, or improvement program that gives participants one or more of the following: (a) a reward; (b) health spending account contribution; (c) premium reduction; or (d) reduced copayment, coinsurance, or deductible; and (4) coverage for licensed physician- or advanced practice registered nurse-prescribed wigs for a person with hair loss caused by a diagnosed medical condition other than androgenetic alopecia.

The bill also increases (1) the annual coverage amount required for medically necessary ostomy appliances and supplies, from $ 1,000 to $ 5,000 and (2) increases the age which certain insurance policies must cover hearing aids as durable medical equipment from 13 to 19.

The bill also 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.

*House Amendment “A” adds the provisions relating to prostheses, human leukocyte antigen testing, wellness incentives, wigs, hearing aids, and colonoscopies.

EFFECTIVE DATE: January 1, 2010

OSTOMY APPLIANCES AND SUPPLIES

The bill increases from $ 1,000 to $ 5,000 the annual coverage amount required in certain health insurance policies for medically necessary ostomy appliances and supplies, including collection devices, irrigation equipment and supplies, and skin barriers and protectors.

PROSTHETIC DEVICES

The bill defines a “prosthetic device” as an artificial device to replace all or part of an arm or leg, including a device containing a microprocessor if determined to be medically necessary by the person's insurer or health care provider. It excludes a device designed exclusively for athletic purposes.

Under the bill, the coverage must be at least equivalent to the coverage Medicare provides for such devices, but may be limited to a prosthetic device that the person's health care provider determines is most appropriate to meet his or her medical needs. (Medicare covers 80% of the cost of prostheses, after a person pays his or her annual deductible. )

The bill prohibits a policy from considering a prosthetic device as durable medical equipment. (Thus, the amount covered cannot count toward a durable medical equipment maximum. )

Coverage Requirements

The bill requires a policy to cover repairs to or replacements of prosthetic devices that the person's heath care provider determines are medically necessary. It excludes coverage of repairs or replacements needed because of misuse or loss of the device. The bill permits a person who is denied coverage for a prosthetic device, or device repair or replacement, to file an external appeal with the insurance commissioner in accordance with law.

The bill prohibits a policy from imposing a coinsurance, copayment, deductible, or other out-of-pocket expense for a prosthetic device that is more restrictive than that imposed on most other policy benefits. It specifies that the deductible limit does not apply to a high-deductible health plan designed to be compatible with federally qualified health savings accounts.

The bill permits a policy to require prior authorization for prosthetic devices, but only in the same manner and to the same extent as prior authorization is required for other policy benefits.

HEARING AIDS

The bill increases the age which certain insurance policies must cover hearing aids as durable medical equipment. Current law requires coverage for children under age 13. The bill requires coverage for children under age 19. By law, a policy may limit coverage to $ 1,000 in a 24-month period.

BONE MARROW TESTING

Coverage Requirements for Bone Marrow Testing

The bill requires coverage for human leukocyte antigen testing, also referred to as histocompatibility locus antigen testing, for A, B, and DR antigens, to determine compatibility for bone marrow transplants. It permits a policy to limit coverage to one covered test in a person's lifetime.

It prohibits a policy, except for a high-deductible policy, from imposing a coinsurance, copayment, deductible, or other out-of-pocket expense for the testing that exceeds 20% of the cost for testing per year.

The bill requires a policy to (1) require bone marrow testing be done at a facility certified under the federal Clinical Laboratory Improvement Act and accredited by the American Society for Histocompatibility and Immunogenetics, or its successor and (2) limit coverage to people who sign up for the National Marrow Donor Program when being tested.

COLONOSCOPIES

The 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, policies 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, based on age, family history, and frequency. Benefits are subject to the same terms and conditions that apply to policy benefits.

WELLNESS INCENTIVES

The bill requires an insurer or other entity writing group health insurance in Connecticut to offer a “reasonably designed” health behavior wellness, maintenance, or improvement program that gives 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. It prohibits the value of any reward or incentive from exceeding 20% of “paid premiums” and requires them to comply with federal nondiscrimination requirements (see BACKGROUND).

The bill requires the insurance commissioner, in consultation with the public health commissioner, to adopt regulations to establish criteria for such 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 rebates. It also makes technical and conforming changes.

WIGS

The bill expands current law regarding health insurance coverage for wigs. By law, certain health insurance policies must provide coverage for an oncologist-prescribed wig for a person with hair loss resulting from chemotherapy. The coverage must be subject to the same terms and conditions applicable to all other policy benefits, but be at least a yearly benefit of $ 350. The bill requires that the coverage also include a licensed physician- or advanced practice registered nurse-prescribed wig for a person with hair loss caused by a diagnosed medical condition, except androgenetic alopecia (e. g. , male-pattern baldness).

The bill applies certain insurance coverage requirements (i. e. , treatment of tumors and leukemia, reconstructive surgery, nondental prosthesis, chemotherapy, and wigs for chemotherapy patients) to policies renewed, amended, or continued in Connecticut on or after January 1, 2010. The requirements already apply to policies issued or delivered in the state.

OTHER COVERAGE REQUIREMENTS

The bill requires certain health insurance policies renewed, amended, or continued in Connecticut to provide coverage for:

1. surgical removal of tumors and outpatient chemotherapy following the surgery;

2. treatment of leukemia, including outpatient chemotherapy;

3. reconstructive surgery, including reconstructive surgery (such as augmentation or reduction mammoplasty and mastopexy) on a breast on which a mastectomy was performed and a nondiseased breast for symmetry;

4. nondental prosthesis, including any maxillo-facial prosthesis used to replace anatomic structures lost during treatment for head and neck tumors or additional appliances essential for the support of such a prosthesis; and

5. an oncologist-prescribed wig for a patient with hair loss resulting from chemotherapy.

Coverage must be subject to the same terms and conditions applicable to other benefits under the policy. But the policy must provide at least a yearly benefit of $ 500 for the surgical removal of tumors, $ 500 for reconstructive surgery, $ 500 for outpatient chemotherapy, $ 350 for a wig, and $ 300 for a nondental prosthesis, unless the prosthesis is due to the surgical removal of breasts because of tumors, in which case the yearly benefit must be at least $ 300 for each breast.

By law, policies issued or delivered in Connecticut must include these benefits.

APPLICABILITY

The coverage requirements relating to ostomy supplies, prosthetic parity, hearing aids, colonoscopies, bone marrow testing, and wellness incentives apply to individual and group health insurance policies delivered, issued, renewed, 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. The bill also applies the requirement to amended policies including such coverage.

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

Applicability of Wig Coverage Requirement

The bill's wig coverage requirement applies to each insurer, hospital or medical service corporation, HMO, or fraternal benefit society that delivers, issues, renews, amends, or continues in Connecticut, on and after January 1, 2010, (1) individual or group health insurance policies that cover (a) basic hospital expenses; (b) basic medical-surgical expenses; (c) major medical expenses; and (d) hospital or medical services, including coverage under an HMO plan, and (2) individual health insurance policies that provide limited benefit health coverage.

BACKGROUND

Ostomy and Related Surgeries

By law, policies that cover ostomy, colostomy, ileostomy, or urostomy surgery must include the benefit. The law prohibits insurers from applying any payments for ostomy appliances and supplies toward any durable medical equipment benefit maximum. And such payments cannot be used to decrease policy benefits that exceed the required coverage amount.

An ostomy is a surgically formed artificial opening in the bowel or intestine. A colostomy is an artificial opening in the colon. An ileostomy is an artificial opening in the small intestine or ileum. An urostomy is an artificial opening in the tubes that run from the kidney to the bladder.

Medically Necessary

The law defines “medically necessary” as health care services that a physician, exercising prudent clinical judgment, would provide to a patient to prevent, evaluate, diagnose, or treat an illness, injury, disease, or its symptoms, and that are:

1. in accordance with generally accepted standards of medical practice;

2. clinically appropriate, in terms of type, frequency, extent, site, and duration and considered effective for the patient's illness, injury, or disease;

3. not primarily for the convenience of the patient, physician, or other health care provider; and

4. and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results.

“Generally accepted standards of medical practice” means standards that are (1) based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community or (2) otherwise consistent with the standards set forth in policy issues involving clinical judgment.

Related Bills

sHB 5093 (File 93), favorably reported by the Insurance Committee, requires a health insurance policy to cover prosthetic devices, and repairs and replacements to them, subject to specified conditions.

sHB 5672 (File 10), favorably reported by the Insurance Committee, increases the age, from 13 to 19, for which certain insurance policies must cover hearing aids as durable medical equipment.

sHB 5673 (File 11), favorably reported by the Insurance Committee, expands current law regarding health insurance coverage for wigs by requiring that the coverage include a licensed physician- or advanced practice registered nurse-prescribed wig for a person with hair loss caused by a diagnosed medical condition, except androgenetic alopecia (e. g. , male-pattern baldness).

sSB 290 (File 5), favorably reported by the Insurance Committee and passed by the Senate, requires certain health insurance policies to provide specified coverage for human leukocyte antigen testing, which determines compatibility for bone marrow transplants.

sSB 638 (File 119), favorably reported by the Insurance Committee and passed by the Senate, 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.

sSB 962 (File 127), favorably reported by the Insurance Committee and passed by the Senate, requires certain health insurance policies to cover “routine patient care” costs incurred while a patient is participating in a clinical trial.

COMMITTEE ACTION

Insurance and Real Estate Committee

Joint Favorable

Yea

15

Nay

4

(02/19/2009)

Appropriations Committee

Joint Favorable

Yea

42

Nay

8

(04/13/2009)