PA 09-188—sHB 5021 (VETOED)

Insurance and Real Estate Committee

Appropriations Committee

AN ACT CONCERNING WELLNESS PROGRAMS AND EXPANSION OF HEALTH INSURANCE COVERAGE

SUMMARY: This act (1) requires group health insurers to offer health wellness programs that provide insured people participation incentives and (2) allows the insurance commissioner, in consultation with the public health commissioner, to adopt regulations regarding such programs. It (1) requires health insurance policies to cover, subject to specified conditions, prosthetic devices and human leukocyte antigen (bone marrow) testing and (2) prohibits insurers from charging an insured person for a second or subsequent colonoscopy a physician orders for him or her in a policy year.

The act expands the insurance coverage required for (1) medically necessary ostomy appliances and supplies, increasing the annual benefit from $1,000 to $5,000; (2) children's hearing aids, requiring coverage for children under age 19, instead of under age 13; and (3) wigs, requiring coverage of at least $350 annually for people diagnosed with alopecia areata (a type of hair loss, which is often temporary in nature), excluding androgenetic alopecia (i. e. , female- or male-pattern baldness), in addition to people with hair loss due to chemotherapy, for whom the benefit is already law.

The act also broadens the applicability of several health insurance benefits required by law, including ostomy supplies, treatment of tumors and leukemia, reconstructive surgery, nondental prosthesis, chemotherapy, and wigs for chemotherapy patients. It does this by requiring all policies delivered, issued, renewed, amended, or continued in Connecticut to include the benefits, instead of only policies delivered or issued in the state.

EFFECTIVE DATE: January 1, 2010

WELLNESS INCENTIVES

The act 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 incentives to participate in the program. The allowed incentives are a (1) reward; (2) health spending account contribution; (3) premium reduction; and (4) reduced copayment, coinsurance, or deductible. The act prohibits the value of any reward or incentive from exceeding 20% of “paid premiums” and requires them to comply with federal nondiscrimination requirements.

The act allows 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 act exempts a permitted reward or incentive from the laws prohibiting rebates and discrimination in insurance.

PROSTHETIC DEVICES

The act defines a “prosthetic device” as an artificial device to replace all or part of an arm or leg. It includes a device containing a microprocessor that an insured person's health care provider determines is medically necessary, but excludes a device designed exclusively for athletic purposes.

The act requires a health insurance policy to provide coverage for prosthetic devices that is at least equivalent to the coverage Medicare provides for such devices. (Medicare covers 80% of the cost of prostheses, after a person pays his or her annual deductible. ) It allows a policy to (1) limit coverage to a prosthetic device that a person's health care provider determines is most appropriate to meet his or her medical needs and (2) to require prior authorization for prosthetic devices, but only in the same manner and to the same extent as it requires prior authorization for other policy benefits.

The act 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 act 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 act 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 a deductible limit does not apply to a high-deductible health plan designed to be compatible with federally qualified health savings accounts.

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

BONE MARROW TESTING

The act requires health insurance policies to cover 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. Under the act, a policy (1) may limit coverage to one covered test in a person's lifetime and (2) cannot impose a coinsurance, copayment, deductible, or other out-of-pocket expense for the testing that exceeds 20% of the cost for testing per year, unless it is a high-deductible policy designed to be compatible with federally qualified health savings accounts.

The act 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

By law, health insurance 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.

The act prohibits 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. Other than this prohibition, benefits are subject to the same terms and conditions that apply to policy benefits. The act specifies that its prohibition does not apply to a high-deductible health plan designed to be compatible with federally qualified health savings accounts.

OSTOMY APPLIANCES AND SUPPLIES

By law, policies that cover ostomy surgery must include coverage for medically necessary ostomy appliances and supplies, including collection devices, irrigation equipment and supplies, and skin barriers and protectors. Ostomy includes colostomy, ileostomy, and urostomy.

The act increases the annual coverage amount for ostomy appliances and supplies from $1,000 to $5,000. 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.

The act applies this coverage requirement to policies issued, delivered, renewed, amended, or continued in Connecticut. Prior law did not apply to policies amended in the state.

HEARING AIDS

The act requires health insurance policies to cover hearing aids for children under age 19, up from those under age 13. By law, a policy (1) must consider hearing aids as durable medical equipment and (2) may limit coverage to $1,000 in a 24-month period.

WIGS

The act requires health insurance policies to provide a yearly benefit of at least $350 to cover a wig a licensed physician or advanced practice registered nurse prescribes for a person with hair loss caused by a diagnosed medical condition of alopecia areata, excluding androgenetic alopecia. The coverage must be subject to the same terms and conditions applicable to all other policy benefits.

By law, policies must provide a yearly benefit of at least $350 for an oncologist-prescribed wig for a person with hair loss resulting from chemotherapy, subject to the same terms and conditions as other policy benefits.

APPLICABILITY OF OTHER REQUIREMENTS BROADENED

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

1. the surgical removal of tumors and related outpatient chemotherapy;

2. treatment of leukemia, including outpatient chemotherapy;

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

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;

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

6. if a group health insurance policy, medically necessary removal of breast implants that were implanted before July 2, 1994.

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: (1) $500 each for the surgical removal of tumors, reconstructive surgery, and outpatient chemotherapy; (2) $350 for a wig; (3) $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; and (4) if a group policy, $1,000 for a breast implant removal.

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

APPLICABILITY OF THE ACT

The act's coverage requirements for prosthetic devices, bone marrow testing, colonoscopy, ostomy supplies, and hearing aids apply 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. The wig coverage and tumor, leukemia, and related benefit requirements also apply to individual health insurance policies that provide limited benefit health coverage. The wellness program requirement and related provisions apply to only group health insurance policies.

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

BACKGROUND

Medically Necessary

The law requires policies to include the following definition of “medically necessary. ” Medically necessary services are 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.

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