OLR Bill Analysis
AN ACT MANDATING INSURANCE COVERAGE OF ESSENTIAL HEALTH BENEFITS AND EXPANDING MANDATED HEALTH BENEFITS FOR WOMEN, CHILDREN AND ADOLESCENTS.
This bill requires certain health insurance policies to cover ten essential health benefits, which are the same benefits the federal Patient Protection and Affordable Care Act (ACA) (P.L. 111-148, as amended) requires policies to cover. It authorizes the insurance commissioner to adopt related regulations.
The bill also requires these policies to cover certain women's health care services, including contraception; immunizations for children, adolescents, and adults; and preventive services for children and youth age 21 or younger. It generally requires policies to cover these services in full with no cost sharing (such as coinsurance, copayments, or deductibles), except for high deductible plans designed to be compatible with federally qualified health savings accounts. Policies may impose cost sharing on contraceptive methods and services rendered by an out-of-network provider. The ACA requires health insurance policies, except grandfathered ones, to cover these women's health services, immunizations, and preventive services with no cost sharing. (Grandfathered plans are those that existed before March 23, 2010 that have not made significant coverage changes since that date.)
With respect to contraception, the bill requires policies to cover a 12-month supply of a contraceptive approved by the U.S. Food and Drug Administration (FDA) when prescribed by a licensed physician, physician assistant, or advanced practice registered nurse (APRN). The supply may be dispensed at one time or at multiple times, but an insured person cannot receive a 12-month supply more than once per plan year.
The bill applies 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.
EFFECTIVE DATE: January 1, 2019
§§ 1, 2, 9 & 10 — ESSENTIAL HEALTH BENEFITS
The bill requires health insurance policies to cover “essential health benefits” and prohibits policies from including a lifetime limit on their dollar value.
“Essential health benefits” are health care services and benefits that fall within the following ten categories:
1. ambulatory patient services;
2. emergency services;
4. maternity and newborn health care;
5. mental health and substance use disorder services, including behavioral health treatment;
6. prescription drugs;
7. rehabilitative and habilitative services and devices;
8. laboratory services;
9. preventive and wellness services and chronic disease management; and
10. pediatric services, including oral and vision care.
The bill authorizes the insurance commissioner to adopt related regulations. The regulations may specify the health care services and benefits that fall within each essential health benefits category.
To the extent an existing state insurance law requires coverage of a health service or benefit that conflicts with the scope of an essential health benefit, the bill requires a policy to cover the service or benefit that provides greater coverage to the insured person, as determined by the insurance commissioner.
Under the bill, no existing state law regarding an ACA requirement supersedes this bill's essential health benefits requirement that provides greater protection to an insured person, unless the essential health benefits requirement prevents the application of an ACA requirement.
§§ 3 & 4 — 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 APRN;
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.
§§ 5 & 6 — IMMUNIZATIONS
The bill requires health insurance policies that cover prescription drugs to also cover the immunizations for children, adolescents, and adults recommended by the American Academy of Pediatrics, American Academy of Family Physicians, and the American College of Obstetricians and Gynecologists. These include, for example, immunizations for influenza, meningitis, tetanus, HPV, hepatitis A and B, measles, mumps, rubella, and varicella.
§§ 7 & 8 — 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 through age six (CGS § 38a-535).
§§ 11 & 12 — CONTRACEPTIVE METHODS AND SERVICES
Current law requires health insurance policies that cover FDA-approved outpatient prescription drugs to also cover FDA-approved prescription contraceptive methods.
The bill instead requires all health insurance policies to cover the following contraceptive methods and services:
1. all FDA-approved contraceptive and sterilization methods;
2. counseling in FDA-approved contraceptive methods and the proper use of them; and
3. routine follow-up care concerning FDA-approved contraceptive methods.
Additionally, the bill requires policies to cover a 12-month supply of an FDA-approved contraceptive prescribed by a licensed physician, physician assistant, or APRN. The supply may be dispensed once or at multiple times, but an insured person cannot receive a 12-month supply of the contraceptive more than once per plan year.
The bill prohibits policies from imposing cost-sharing requirements for these contraceptive methods and services, except (1) when out-of-network providers render them and (2) for high deductible plans designed to be compatible with federally qualified health savings accounts.
The bill allows health carriers (e.g., insurers and HMOs) 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.
Insurance and Real Estate Committee
Joint Favorable Substitute