OLR Bill Analysis

HB 5023

AN ACT REQUIRING HEALTH INSURANCE COVERAGE FOR WOUND CARE FOR INDIVIDUALS WITH EPIDERMOLYSIS BULLOSA.

SUMMARY:

This bill requires certain insurance policies to cover wound care supplies administered under a physician's direction for the medically necessary treatment of epidermolysis bullosa.

EFFECTIVE DATE: January 1, 2010

APPLICABILITY

The bill applies to individual and group health insurance policies delivered, issued, renewed, amended, or continued in Connecticut on and after January 1, 2010 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

Epidermolysis Bullosa

Epidermolysis bullosa (EB) refers to a group of rare skin diseases characterized by recurring painful blisters and open sores, in response to minor injury, heat, or friction, as a result of the unusually fragile nature of the person's skin. Some severe forms may involve the eyes, tongue, and esophagus, and some may produce scarring and disabling musculoskeletal deformities.

There is no cure for EB. Treatment often is focused on wound care to minimize pain, infection, and other complications.

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; and

3. not primarily for the convenience of the patient, physician, or other health care provider 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 (CGS 38a-482a and 38a-513c).

COMMITTEE ACTION

Insurance and Real Estate Committee

Joint Favorable

Yea

17

Nay

2

(02/10/2009)