Connecticut Seal

General Assembly

 

Raised Bill No. 297

February Session, 2018

 

LCO No. 1375

 

*01375_______PH_*

Referred to Committee on PUBLIC HEALTH

 

Introduced by:

 

(PH)

 

AN ACT CONCERNING HEALTH INSURANCE COVERAGE OF IN-NETWORK HEALTH CARE SERVICES AND REVIEW OF ADVERSE DECISIONS BASED ON MEDICAL NECESSITY.

Be it enacted by the Senate and House of Representatives in General Assembly convened:

Section 1. (NEW) (Effective January 1, 2019) (a) Each insurance company, hospital service corporation, medical service corporation, health care center, fraternal benefit society or other entity that delivers, issues for delivery, renews, amends or continues in the state an individual health insurance policy, as defined in section 38a-469 of the general statutes, that provides coverage to an insured or enrollee shall cover in-network health care services provided to the insured or enrollee.

(b) Nothing in this section shall be construed to prohibit utilization review, as defined under section 38a-591a of the general statutes, as amended by this act.

(c) Any insurance company, hospital service corporation, medical service corporation, health care center, fraternal benefit society or other entity providing coverage for health care services under subsection (a) of this section may seek recovery from an insured or enrollee for the cost of such services if such services are not medically necessary, provided the amount of such recovery shall not exceed the Medicare reimbursement rate for such services. For the purposes of this subsection, "medically necessary" has the same meaning as provided in section 38a-482a of the general statutes.

Sec. 2. (NEW) (Effective January 1, 2019) (a) Each insurance company, hospital service corporation, medical service corporation, health care center, fraternal benefit society or other entity that delivers, issues for delivery, renews, amends or continues in the state a group health insurance policy, as defined in section 38a-469 of the general statutes, that provides coverage to an insured or enrollee shall cover in-network health care services provided to the insured or enrollee.

(b) Nothing in this section shall be construed to prohibit utilization review, as defined in section 38a-591a of the general statutes, as amended by this act.

(c) Any insurance company, hospital service corporation, medical service corporation, health care center, fraternal benefit society or other entity providing coverage for health care services under subsection (a) of this section may seek recovery from an insured or enrollee for the cost of such services if such services are not medically necessary, provided the amount of such recovery shall not exceed the Medicare reimbursement rate for such services. For the purposes of this subsection, "medically necessary" has the same meaning as provided in section 38a-482a of the general statutes.

Sec. 3. Subdivision (7) of section 38a-591a of the general statutes is repealed and the following is substituted in lieu thereof (Effective January 1, 2019):

(7) "Clinical peer" means (A) a physician [or other health care professional] who [(A)] holds a nonrestricted license in a state of the United States and in the same or similar specialty as typically manages the medical condition, procedure or treatment under review, and (B) for a review specified under subparagraph (B) or (C) of subdivision (38) of this section concerning (i) a child or adolescent substance use disorder or a child or adolescent mental disorder, a physician or other health care professional who holds (I) a national board certification in child and adolescent psychiatry, or (II) a doctoral level psychology degree with training and clinical experience in the treatment of child and adolescent substance use disorder or child and adolescent mental disorder, as applicable, or (ii) an adult substance use disorder or an adult mental disorder, holds (I) a national board certification in psychiatry, or (II) a doctoral level psychology degree with training and clinical experience in the treatment of adult substance use disorders or adult mental disorders, as applicable.

This act shall take effect as follows and shall amend the following sections:

Section 1

January 1, 2019

New section

Sec. 2

January 1, 2019

New section

Sec. 3

January 1, 2019

38a-591a(7)

Statement of Purpose:

To require health insurance coverage of in-network health care services.

[Proposed deletions are enclosed in brackets. Proposed additions are indicated by underline, except that when the entire text of a bill or resolution or a section of a bill or resolution is new, it is not underlined.]