Connecticut Seal

General Assembly

 

Raised Bill No. 381

February Session, 2018

 

LCO No. 1747

 

*01747_______INS*

Referred to Committee on INSURANCE AND REAL ESTATE

 

Introduced by:

 

(INS)

 

AN ACT CONCERNING DISCLOSURE OF CERTAIN THIRD-PARTY ADMINISTRATOR FEES.

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

Section 1. Section 38a-479 of the general statutes is repealed and the following is substituted in lieu thereof (Effective January 1, 2019):

(a) As used in this section and section 38a-479b:

(1) "Contracting health organization" means a managed care organization, as defined in section 38a-478, or a preferred provider network, as defined in section 38a-479aa.

(2) "Provider" means a physician, surgeon, chiropractor, podiatrist, psychologist, optometrist, dentist, naturopath or advanced practice registered nurse licensed in this state or a group or organization of such individuals, who has entered into or renews a participating provider contract with a contracting health organization to render services to such organization's enrollees and enrollees' dependents.

(b) Each contracting health organization shall establish and implement a procedure to provide to each provider:

(1) Access via the Internet or other electronic or digital format to the contracting health organization's fees for (A) the current procedural terminology (CPT) codes or current dental terminology (CDT) codes applicable to such provider's specialty, (B) the Health Care Procedure Coding System (HCPCS) codes applicable to such provider, and (C) such CPT codes, CDT codes and HCPCS codes as may be requested by such provider for other services such provider actually bills or intends to bill the contracting health organization, provided such codes are within the provider's specialty or subspecialty; and

(2) Access via the Internet or other electronic or digital format to the contracting health organization's policies and procedures regarding (A) payments to providers, (B) providers' duties and requirements under the participating provider contract, (C) inquiries and appeals from providers, including contact information for the office or offices responsible for responding to such inquiries or appeals and a description of the rights of a provider, enrollee and enrollee's dependents with respect to an appeal.

(c) The provisions of subdivision (1) of subsection (b) of this section shall not apply to any provider whose services are reimbursed in a manner that does not utilize current procedural terminology (CPT) or current dental terminology (CDT) codes.

(d) The fee information received by a provider pursuant to subdivision (1) of subsection (b) of this section is proprietary and shall be confidential, and the procedure adopted pursuant to this section may contain penalties for the unauthorized distribution of fee information, which may include termination of the participating provider contract.

Sec. 2. Subsection (a) of section 38a-479b of the general statutes is repealed and the following is substituted in lieu thereof (Effective January 1, 2019):

(a) No contracting health organization shall make material changes to a provider's fee schedule except as follows:

(1) At one time annually, provided providers are given at least ninety days' advance notice by mail, electronic mail or facsimile by such organization of any such changes. With respect to a dental plan, such notice shall include the maximum allowable charge for each dental procedure code. Upon receipt of such notice, a provider may terminate the participating provider contract with at least sixty days' advance written notice to the contracting health organization;

(2) At any time for the following, provided providers are given at least thirty days' advance notice by mail, electronic mail or facsimile by such organization of any such changes:

(A) To comply with requirements of federal or state law, regulation or policy. If such federal or state law, regulation or policy takes effect in less than thirty days, the organization shall give providers as much notice as possible;

(B) To comply with changes to the medical data code sets set forth in 45 CFR 162.1002, as amended from time to time;

(C) To comply with changes to national best practice protocols made by the National Quality Forum or other national accrediting or standard-setting organization based on peer-reviewed medical literature generally recognized by the relevant medical community or the results of clinical trials generally recognized and accepted by the relevant medical community;

(D) To be consistent with changes made in Medicare pertaining to billing or medical management practices, provided any such changes are applied to relevant participating provider contracts where such changes pertain to the same specialty or payment methodology;

(E) If a drug, treatment, procedure or device is identified as no longer safe and effective by the federal Food and Drug Administration or by peer-reviewed medical literature generally recognized by the relevant medical community;

(F) To address payment or reimbursement for a new drug, treatment, procedure or device that becomes available and is determined to be safe and effective by the federal Food and Drug Administration or by peer-reviewed medical literature generally recognized by the relevant medical community; or

(G) As mutually agreed to by the contracting health organization and the provider. If the contracting health organization and the provider do not mutually agree, the provider's current fee schedule shall remain in force until the annual change permitted pursuant to subdivision (1) of this subsection.

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

Section 1

January 1, 2019

38a-479

Sec. 2

January 1, 2019

38a-479b(a)

Statement of Purpose:

To subject dentists, dental plans and procedures to certain statutory provisions concerning contracts between providers and contracting health organizations.

[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.]