OLR Bill Analysis
sSB 586 (File 242, as amended by Senate "A" and "B")*
AN ACT EXPANDING MANDATED HEALTH BENEFITS FOR WOMEN, CHILDREN AND ADOLESCENTS.
This bill requires certain health insurance policies to cover (1) specified women's health care services, including contraception; (2) immunizations for children, adolescents, and adults; and (3) preventive services for children and youth age 21 or younger (§§ 1 – 8). The services generally must be covered in full with no cost sharing (such as coinsurance, copayments, or deductibles). The cost-sharing prohibition does not apply to high deductible health plans designed to be compatible with federally qualified health savings accounts. Also, health carriers (e.g., insurers and HMOs) may impose cost-sharing requirements for contraceptive methods and services received from out-of-network providers.
Currently, health insurance policies, except grandfathered ones, must cover these services with no cost sharing pursuant to Section 2713 of the federal Patient Protection and Affordable Care Act (ACA, P. L. 111-148, as amended). (Grandfathered policies are those that were in existence before March 23, 2010 that have not made significant changes to their coverage.)
The bill also requires certain health policies and contracts to offer a special enrollment period to eligible pregnant women (§§ 501 – 505). A special enrollment period is a time, outside of the open enrollment period, when eligible individuals may apply for health insurance. These provisions apply to individual health insurance policies subject to the ACA and contracts offered by hospital and medical service corporations.
*Senate Amendment “A” (1) removes a prohibition on step therapy and prior authorization requirements for contraception coverage and (2) allows health carriers to impose cost sharing requirements for contraception methods and services delivered by out-of-network providers.
*Senate Amendment “B” requires certain health policies and contracts to offer a special enrollment period to eligible pregnant women.
EFFECTIVE DATE: January 1, 2018
§§ 1-8 — APPLICABILITY
The bill's coverage provisions (described below) 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; or (4) hospital or medical services, including those provided under an HMO plan. Because of the federal Employee Retirement Income Security Act (ERISA), state insurance benefit mandates do not apply to self-insured benefit plans.
§§ 1 & 2 — WOMEN'S HEALTH SERVICES
Under the bill, health insurance policies must cover the following services:
1. domestic and interpersonal violence screening and counseling for women;
2. tobacco use intervention and cessation counseling for women who use tobacco;
3. well-woman visits for women younger than age 65;
4. breast cancer chemoprevention counseling for women at increased risk for breast cancer due to family history or prior personal history of breast cancer, positive genetic testing, or other indications as determined by the woman's physician or advanced practice registered nurse;
5. breast cancer risk assessment, genetic testing, and counseling;
6. screening for chlamydia, cervical and vaginal cancer, gonorrhea, and human immunodeficiency virus for sexually active women;
7. human papillomavirus (HPV) screening for women age 30 or older with normal cytology results;
8. sexually transmitted infections counseling for sexually active women;
9. anemia screening and folic acid supplements for pregnant women and women likely to become pregnant;
10. for pregnant women, hepatitis B screening, rhesus incompatibility screening, and follow-up rhesus incompatibility testing if the women are at increased risk for it;
11. syphilis screening for pregnant women and women at increased risk for syphilis;
12. urinary tract and other infection screening for pregnant women;
13. breastfeeding support and counseling for women who are pregnant or breastfeeding;
14. breastfeeding supplies, including a breast pump, for women who are breastfeeding;
15. gestational diabetes screening for women who are 24 to 28 weeks pregnant and women at increased risk for gestational diabetes; and
16. osteoporosis screening for women age 60 or older.
§§ 3 & 4 — IMMUNIZATIONS
The bill requires health insurance policies that cover prescription drugs to also cover immunizations for children, adolescents, and adults that are recommended by the American Academy of Pediatrics, American Academy of Family Physicians, and the American College of Obstetricians and Gynecologists. These include immunizations such as influenza, meningitis, tetanus, HPV, hepatitis A and B, measles, mumps, rubella, and varicella.
§§ 5 & 6 — PREVENTIVE SERVICES FOR CHILDREN AND YOUTH
The bill requires health insurance policies to cover preventive services for people age 21 or younger in accordance with the most recent edition of the American Academy of Pediatrics' Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. These include services such as behavioral and developmental assessments; iron and fluoride supplements; and screening for autism, vision or hearing impairment, lipid disorders, and tuberculosis.
Existing law, unchanged by the bill, requires group health insurance policies to cover preventive pediatric care for a child up to age six (CGS § 38a-535).
§§ 7 & 8 — CONTRACEPTIVE METHODS AND SERVICES
Current law requires health insurance policies that cover outpatient prescription drugs approved by the U.S. Food and Drug Administration (FDA) to also cover FDA-approved contraceptive methods.
The bill instead requires health insurance policies to cover the following contraceptive methods and services:
1. all FDA-approved contraceptive and sterilization methods;
2. counseling in (a) FDA-approved contraceptive methods and (b) the proper use of FDA-approved contraceptive equipment and supplies; and
3. routine follow-up care concerning FDA-approved contraceptive methods, equipment, and supplies.
The bill allows health carriers to impose step therapy or prior authorization requirements on these contraceptive methods and services. (Step therapy is a protocol establishing the sequence for prescribing drugs that generally requires patients to try less expensive drugs before higher cost drugs.)
Under existing law, unchanged by the bill, religious employers and individuals may request that their insurance policies not cover prescriptive contraceptive methods if they are contrary to their bona fide religious tenets.
§§ 501-505 — SPECIAL ENROLLMENT PERIOD
The bill requires certain health policies and contracts to offer a special enrollment period to eligible pregnant women. A special enrollment period is a time, outside of the open enrollment period, when eligible individuals may apply for health insurance. These provisions apply to individual health insurance policies subject to the ACA and contracts offered by hospital and medical service corporations. They do not apply to (1) the state employee health benefit plan or (2) a fully insured group health insurance policy sponsored by a municipality.
Under the bill, the health carrier must provide a special enrollment period for up to 30 days after a pregnancy commences, as certified by a licensed health care provider acting within his or her scope of practice. For a woman who enrolls in coverage during the special enrollment period, coverage must be effective on the first day of the month in which the pregnancy is certified.
Under the bill, coverage is limited to eligible employees not covered by insurance that meets the ACA's essential health benefits or the requirements of Connecticut's insurance laws. (The bill does not define “eligible employee.” As a result, it is unclear who can take advantage of the special enrollment period. The provisions affect individual health care policies, for which eligibility generally is not tied to an employment relationship.)
Under the bill, an individual may enroll in a policy offered on the Connecticut health insurance exchange (i.e., Access Health CT) or off the exchange.
Lastly, the bill conforms state law to federal law with respect to special enrollment periods generally by specifying that policies must provide special enrollment periods to eligible individuals as set forth in federal law.
Insurance and Real Estate Committee
Joint Favorable Substitute