PA 09-51—HB 5023

Insurance and Real Estate Committee

Appropriations Committee

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

SUMMARY: This act requires certain insurance policies to cover wound care supplies that are medically necessary to treat epidermolysis bullosa and administered under a physician's direction.

The act 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.

EFFECTIVE DATE: January 1, 2010

BACKGROUND

Epidermolysis Bullosa

Epidermolysis bullosa (EB) refers to a group of rare skin diseases characterized by recurring blisters and open sores.

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. 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).

OLR Tracking: JLK: VR; JL: TS