PA 16-205—sSB 433

Insurance and Real Estate Committee

AN ACT CONCERNING STANDARDS AND REQUIREMENTS FOR HEALTH CARRIERS' PROVIDER NETWORKS AND CONTRACTS BETWEEN HEALTH CARRIERS AND PARTICIPATING PROVIDERS

SUMMARY: This act establishes requirements for health carriers' (e. g. , insurers and HMOs) provider networks, contracts, and directories and authorizes the insurance commissioner to adopt implementing regulations.

The act requires health carriers to establish and maintain adequate provider networks to assure that all covered benefits are accessible to covered individuals without unreasonable travel or delay. It requires that covered individuals have access to emergency services at all times. Prior law required networks to be consistent with (1) the National Committee for Quality Assurance's (NCQA) network adequacy requirements or (2) URAC's provider network access and availability standards. (URAC, formerly known as the Utilization Review Accreditation Commission, and NCQA are nonprofit health quality organizations. )

The act requires the insurance commissioner to review and determine the sufficiency of a health carrier's provider network, subject to specified criteria. Additionally, it requires a carrier to provide benefits at the in-network level of coverage when a nonparticipating provider performs covered services for a covered individual if a participating provider is not available in the network.

The act requires carriers to (1) make a good faith effort to give written notice to a participating provider's patients when the provider leaves the network and (2) provide for the continuity of care for patients in an active course of treatment with the provider.

It also (1) establishes standards for contracts between a health carrier and its participating providers, specifying provisions that the contracts must contain, and (2) requires a carrier to maintain current provider directories on its website that it updates at least monthly.

Lastly, the act prohibits a provider from collecting, or attempting to collect, from an insured patient any money the patient's health carrier owes to the provider. Under existing law and unchanged by the act, it is an unfair trade practice for a provider to request payment from a health care plan enrollee, except for a copayment, deductible, coinsurance, or other out-of-pocket expense, for covered health care services (CGS 20-7f).

EFFECTIVE DATE: January 1, 2017

1 – NETWORK ADEQUACY REQUIREMENTS

Filing of Network, Access Plan, and Material Change

The act requires each health carrier, beginning January 1, 2017, to file with the insurance commissioner each existing provider network and access plan (described below). For each new network a carrier plans to offer after that date, the carrier must file the new network and access plan with the commissioner within 30 days before offering the network.

A carrier must notify the commissioner of any material change to a network within 15 days after the change and must file an update to the network within 30 days after the change. The act defines a “material change” as (1) a change of 25% or more in the participating providers in the network or (2) any change that makes the network noncompliant with the network adequacy requirements. Such changes include, for example, a significant reduction in the number of primary or specialty care providers in the network, a change in inclusion of a major health system (e. g. , a hospital or affiliated entities) that causes the network to be significantly different from what a covered individual initially purchased, or other changes the commissioner deems material.

Sufficiency of Network

The act requires the insurance commissioner to determine the sufficiency of a health carrier's network. In determining sufficiency, she may refer to any reasonable criteria, including the following:

1. ratio of participating providers to covered individuals by specialty;

2. ratio of primary care providers to covered individuals;

3. geographic accessibility of participating providers;

4. geographic variation and dispersion of the state's population;

5. wait times for appointments with participating providers;

6. participating providers' hours of operation;

7. network's ability to meet covered individuals' needs;

8. availability of other health care delivery system options, including telemedicine, centers of excellence, and mobile clinics;

9. volume of technological and specialty care services available to those who require them;

10. extent to which participating providers are accepting new patients;

11. degree to which (a) participating providers are authorized to admit patients to participating hospitals and (b) hospital-based providers are participating; and

12. regionalization of specialty care.

Access Plan

A health carrier's access plan must be in a form the commissioner prescribes and must include the following:

1. the carrier's procedures for making and authorizing referrals within and outside its network;

2. the carrier's procedures for ongoing monitoring and assuring the sufficiency of its network;

3. factors used to build the network, including criteria used to select and tier health care providers and facilities;

4. the carrier's efforts to address the needs of all covered persons and to include various types of essential community providers (i. e. , those serving low-income, medically underserved people) in its network;

5. methods for assessing the health care needs of covered individuals and their satisfaction with the health care services provided;

6. the carrier's methods for informing covered individuals of covered benefits, including processes for (a) grievances and appeals, (b) choosing or changing participating providers, (c) updating participating provider directories, and (d) approving emergency and urgent care;

7. methods for covered individuals to change who they designate as a primary care provider;

8. the carrier's system for ensuring coordination and continuity of care for covered individuals referred to specialty physicians or using covered ancillary services;

9. the carrier's proposed plan for providing continuity of care for covered individuals in the event of (a) a contract termination between the carrier and a participating provider or (b) the health carrier's insolvency or other inability to continue operations;

10. the process for monitoring access to certain specialist services (i. e. , emergency room care, anesthesiology, radiology, hospitalist care, and pathology and laboratory services) at the carrier's participating hospitals;

11. the carrier's efforts to ensure that its participating providers meet available and appropriate quality of care standards and health outcomes;

12. the carrier's accreditation by (a) NCQA, affirming that the carrier meets NCQA's network adequacy requirements or (b) URAC, affirming that the carrier meets URAC's provider network access and availability standards; and

13. any other information the commissioner requires to determine the carrier's compliance with the act.

The act requires a health carrier to post each access plan on its website and make it available at its Connecticut business location and to anyone upon request. But the carrier may exclude from a publicly available access plan any information that it deems proprietary. A carrier may also ask the commissioner not to disclose proprietary information under the Freedom of Information Act.

Carrier Requirements

The act requires a health carrier to do the following:

1. maintain adequate arrangements with providers to assure that its covered individuals have reasonable access to participating providers near their homes or jobs;

2. monitor the ability, clinical capacity, and legal authority of its participating providers to provide all covered benefits to its covered individuals;

3. establish and maintain procedures for notifying a participating provider of the specific covered health care services for which he or she is responsible;

4. notify participating providers of their obligations to (a) collect coinsurance, deductibles, or copayments from covered individuals and (b) notify individuals of their financial obligations for noncovered benefits before delivering health care services, if possible;

5. establish and maintain procedures by which a participating provider may determine, in a timely manner when benefits are provided, whether an individual is covered or is within a grace period for premium payment during which the carrier may hold a claim for health care services pending receipt of premium payment;

6. notify a health care provider or facility of the provider's or facility's network participation status in a timely manner;

7. notify participating providers of their responsibilities with respect to the carrier's administrative policies and programs, including payment terms, utilization review, quality assessment and improvement programs, credentialing, grievance and appeals processes, reporting if the practice is not accepting new patients, confidentiality requirements, and obtaining necessary referrals to nonparticipating providers; and

8. establish and maintain procedures for resolving disputes between it and a participating provider.

Carrier Prohibitions

The act prohibits a health carrier from doing the following:

1. offering or providing an inducement to a participating provider to encourage the provider to provide less than medically necessary health care services to a covered individual;

2. prohibiting a participating provider from discussing any specific treatment option with covered individuals or advocating on behalf of covered individuals during utilization review or grievance and appeals processes; or

3. penalizing a participating provider because the provider reports in good faith to state or federal authorities a carrier's action or practice that jeopardizes patient health or welfare.

Selecting and Tiering Participating Providers

The act requires a health carrier to develop standards for selecting and tiering participating providers and provider specialties. The carrier must make the standards available to the insurance commissioner for her review and to the public, in plain language, on its website.

The act defines a “tiered network” as a network of participating providers that identifies and groups health care providers and facilities into specific categories for which different reimbursement, cost-sharing, or access requirements apply for the same health care services.

Under the act, a carrier cannot establish standards that would do the following:

1. allow the carrier to discriminate against high-risk populations by excluding or tiering providers located in a geographic area that presents higher-than-average claims, losses, or health care service utilization;

2. exclude providers because they treat or specialize in treating populations that present higher-than-average claims, losses, or health care service utilization; or

3. allow the carrier to discriminate against a provider acting within the scope of his or her license or certification.

The act specifies that it does not require a carrier to contract with every provider or facility willing to abide by its participation terms. It also does not require a carrier, the carrier's intermediaries, or a contracted provider network to (1) employ specific providers or (2) contract with more providers than are needed to maintain a sufficient network.

Coverage at In-Network Level of Benefits

Under the act, a health carrier generally must provide benefits at the in-network level of coverage when a nonparticipating provider performs covered services for a covered individual if a participating provider is not available in the network. Specifically, a carrier must establish and maintain a process that ensures a covered individual receives covered benefits at the in-network level of benefits and cost sharing from a nonparticipating provider when the carrier's network is either insufficient or sufficient but lacking a (1) type of participating provider needed to provide the covered benefit or (2) participating provider available without unreasonable travel or delay.

A carrier must disclose to a covered individual how to request a covered benefit from a nonparticipating provider at the in-network level of benefits when the individual is diagnosed with a condition or disease that requires specialty care and the carrier (1) does not have a participating provider of the required specialty with the training and expertise to treat the person or (2) cannot provide reasonable access to such a participating provider without unreasonable travel or delay.

The carrier must respond to a request in a timely fashion appropriate for the individual's condition but no longer than allowed under the law for an external review. It must treat the health care service as being performed in-network, including counting the individual's cost sharing toward the out-of-pocket maximum limit applicable to in-network services.

The carrier must document all such requests and provide the documentation to the commissioner upon request.

The act prohibits a carrier from using this process as a substitute for maintaining an adequate network. It also prohibits a covered individual from using the process to circumvent using covered benefits available through the carrier's network.

The act specifies that it does not affect the rights or remedies available under state or federal law relating to grievances and appeals.

When a Participating Provider Leaves the Network

The act, as under existing law, requires that a health carrier and participating provider provide each other at least 60 days' notice before a carrier removes the provider from the network or the provider leaves the network.

The act requires a participating provider who is removed from or leaving the network to give the carrier a list of his or her patients covered under a network plan of the carrier. The carrier must make a good faith effort, within 30 days after providing or receiving a notice of termination, to give written notice of the provider's departure to each covered patient being treated on a regular basis.

Continuity of Care

The act requires a health carrier to establish and maintain continuity of care procedures to transition a covered individual in an active course of treatment with a participating provider to a different participating provider after the original one is removed from or leaves the carrier's network.

Under the act, an “active course of treatment” is medically necessary care provided during the second or third trimester of pregnancy or a medically necessary, ongoing course of treatment for a condition that (1) is life-threatening; (2) is serious; or (3) will worsen or interfere with anticipated outcomes if the treatment is discontinued, according to the treating provider. A “serious condition” is one that requires complex, ongoing care such as chemotherapy, radiation therapy, or postoperative visits.

In addition to requiring the carrier to provide notice that a provider is leaving the network (as described above), the act requires the carrier to also give the covered individual a list of the same type of available participating providers in the same geographic area and the procedures for requesting continuity of care.

A carrier's continuity of care procedures must provide that:

1. a covered individual or his or her authorized representative may request continuity of care;

2. a continuity of care request for a covered individual undergoing an active course of treatment must be reviewed by the carrier's medical director after consulting with the treating provider, as long as the treating provider is not leaving the network for cause; and

3. the continuity of care period for an individual in the second or third trimester of pregnancy must extend through the postpartum period.

Under the act, the continuity of care period for someone undergoing an active course of treatment must last until the earliest of:

1. the end of the course of treatment;

2. 90 days after the treating provider leaves the network, unless the medical director decides a longer period is needed;

3. the date the individual's care is transitioned to another participating provider;

4. the date benefit limitations under the plan are met or exceeded; or

5. the date the carrier determines the care is no longer medically necessary.

The act specifies that a carrier can grant a continuity of care period only if the treating provider leaving the network agrees in writing to (1) accept the same payment and terms as when he or she was participating in the network and (2) not seek any payment from a covered individual for any amount he or she would not have been responsible for if the provider was still in the network.

2 – PROVIDER CONTRACT REQUIREMENTS

Required Provisions

The act specifies certain provisions that a contract between a health carrier and a participating provider (“provider contract”) must contain. The requirements apply to contracts entered into, renewed, or amended on or after January 1, 2017.

The act requires a provider contract to include a specified hold harmless provision that protects covered individuals from being billed for more than they are required to pay for services covered under the plan. It also requires a provider contract to include a provision stating that if a carrier becomes insolvent or operations cease, the participating provider must continue delivering covered health care services to covered individuals until the date the individual's coverage under the plan ends or the provider contract would have ended had the carrier remained in operation, whichever is earlier.

Under the act, a provider contract must require a participating provider to make health records available to state and federal authorities investigating grievances or assessing the quality of care provided to covered individuals. The contract must require the provider to comply with applicable state and federal laws on the confidentiality of health records and an individual's rights to view, obtain copies of, or amend his or her health records.

In addition, the act requires a provider contract to define “timely notice” and “material change” to comply with a requirement that the carrier give providers timely notice of any material changes to the contract.

The act specifies that a provider contract's terms must:

1. be construed in favor of covered individuals;

2. survive the termination of the contract; and

3. supersede any agreement between a provider and a covered individual, or his or her authorized representative, that is contrary to the act.

Prohibitions

Under the act, a provider contract cannot conflict with the provisions contained in the carrier's network plan or the act's network adequacy, provider contract, and provider directory requirements.

The act prohibits carriers and participating providers that are parties to a provider contract from assigning or delegating any right or responsibility under the contract without the other party's written consent.

Required Disclosure

The act requires a carrier or its intermediary, when a provider contract is signed, to disclose to the provider all provisions and other documents incorporated by reference in the contract. An “intermediary” is a person or entity authorized to negotiate and execute provider contracts with carriers on behalf of providers.

Contracts between Carriers and Intermediaries

The act requires contracts between a health carrier and an intermediary to comply with certain provisions. The requirements apply to contracts entered into, renewed, or amended on or after January 1, 2017.

Under the act, a carrier cannot delegate to an intermediary the carrier's responsibilities to monitor the offering of covered benefits to covered individuals. To the extent a carrier delegates other responsibilities to an intermediary, the carrier remains responsible for the intermediary's compliance with the act's provider contract requirements.

The act gives the carrier the right to approve or disapprove a provider's or facility's participation status in the carrier's network, whether its own or a subcontracted network. It requires the carrier to keep at its principal place of business in Connecticut copies of all intermediary subcontracts or at least have access to all such contracts. Under the act, a carrier has the right, upon 20 days' prior written request, to make copies of all such subcontracts for regulatory review purposes.

The act requires an intermediary, if applicable, to give a carrier documentation of the health care services used and claims paid. An intermediary must also keep at its principal place of business in Connecticut, for regulatory review purposes, books, records, financial information, and documentation of health care services covered individuals received, for as long as the insurance commissioner prescribes. An intermediary must allow the commissioner access to such information as needed for her to determine compliance with the act's network adequacy and provider contract requirements.

Under the act, a health carrier must monitor the timeliness and appropriateness of (1) payments an intermediary makes to participating providers and (2) health care services covered individuals receive.

If an intermediary becomes insolvent, the act gives a health carrier the right to require the intermediary to assign to it the provider contract provisions that address a provider's obligation to provide covered benefits. If such assignment is required, the carrier remains obligated to pay the participating provider under the same terms and conditions as applied before the insolvency.

Disputes

Under the act, the insurance commissioner cannot arbitrate, mediate, or settle disputes (1) over a carrier's decision not to include a provider or facility in its network or (2) between a carrier, an intermediary, or a participating provider that arise under a provider contract or its termination.

3 – PROVIDER DIRECTORY REQUIREMENTS

Accurate Directories Required

The act requires a health carrier to post on its website a current directory, updated at least monthly, of its participating providers (“provider directory”) for each of its network plans. Consumers must be able to view the directories on a carrier's website without having to create or access an account or enter a policy or contract number. A carrier must provide a printed copy of a directory or information from it upon request of a covered individual or his or her authorized representative.

Contents of a Directory

The act requires a carrier to include a plain language description of the following in each provider directory:

1. the criteria used to build the network and, if applicable, tier participating providers;

2. methods the carrier uses to designate the different tiers in the network and in which tier each participating provider is placed using a name, symbol, or grouping that allows the consumer to identify the tiers; and

3. if applicable, a statement that an authorization or referral may be required to access some participating providers.

A provider directory must also include a customer service email address and telephone number or a website address that consumers and covered individuals can use to inform the carrier of inaccuracies in the provider directory.

A carrier must clearly identify which provider directory applies to which network plan. And each directory must accommodate individuals with disabilities and individuals with limited English proficiency.

Online Directories. For each participating provider, a carrier's online provider directory must include the provider's name, gender, specialty, board certification, participating office locations, medical group affiliations, facility affiliations, participating facility affiliations, languages the provider and staff speak other than English, contact information, and whether the provider is accepting new patients.

For each participating hospital, the online directory must include the name and the type of hospital (e. g. , acute, rehabilitation, children's, cancer), the participating location, the hospital's accreditation status, and its telephone number.

For each participating facility other than a hospital, the online directory must include the facility name, the types of health care services performed there, the participating locations, and its telephone number.

Online directories must also make available the sources of, and any limitations on, their information.

Print Directories. A carrier's printed provider directories must be available upon request and include the following information:

1. for a participating provider, the provider's name, contact information, specialty, participating office locations, languages spoken other than English, and whether he or she is accepting new patients;

2. for a participating hospital, the name and the type of hospital, participating location, and telephone number; and

3. for a participating facility other than a hospital, by type, the name and the type of facility, type of health care services performed there, participating locations, and telephone number.

A carrier must state in a printed directory that the information is accurate as of the print date and the consumer should consult the carrier's online provider directory or call the carrier for more information.

Audit Required

The act requires a carrier to periodically audit a reasonable sample size of its provider directories for accuracy. It must keep the audit documentation and provide it to the insurance commissioner upon her request.

1 – ENFORCEMENT

If the insurance commissioner determines that a health carrier has not complied with the act's network adequacy, provider contract, or provider directory requirements, the health carrier must implement a corrective action plan as directed by the commissioner. The commissioner may take any action authorized under the state's insurance laws to bring a carrier into compliance. Under existing law, the commissioner may fine a carrier up to $15,000 per violation (CGS 38a-2).

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