CHAPTER 700c

HEALTH INSURANCE

Table of Contents

Sec. 38a-472a. Medical provider indemnification agreements prohibited.

Sec. 38a-472c. Dental policies. Estimate of reimbursement. Material adjustments to fee schedules for in-network providers. Notice.

Sec. 38a-472h. Fees charged by dentists, optometrists and ophthalmologists for noncovered benefits. Notice and posting required.

Sec. 38a-472j. Restrictions applicable to cost-sharing for covered benefits. Regulations.

Sec. 38a-472k. Disability income policies. Discretionary clauses prohibited. Regulations.

Sec. 38a-475. Precertification of long-term care policies under the Connecticut Partnership for Long-Term Care. Regulations.

Sec. 38a-476. Preexisting condition coverage.

Sec. 38a-477aa. Cost-sharing and health care provider reimbursements for emergency services and surprise bills.

Sec. 38a-477cc. Contracts for pharmacy services with health carriers or pharmacy benefits managers.

Sec. 38a-477dd. Contracts with health carriers. Certain provisions concerning disclosures to covered persons prohibited.

Sec. 38a-477ee. Mental health and substance use disorder benefits. Nonquantitative treatment limitations. Reports. Public hearings. Regulations.

Sec. 38a-478j. Coinsurance and deductible payments based on negotiated discounts.

Sec. 38a-478r. Emergency rooms. Prudent layperson standard. Presenting symptoms or final diagnosis as basis for coverage. Mandatory coverage for medically necessary health care services for emergency medical conditions.

Sec. 38a-479. Definitions. Access to fee schedules. Fee information to be confidential.

Sec. 38a-479b. Material changes to fee schedules. Return of payment by provider. Appeals. Filing of claim by provider under other applicable insurance coverage. Certain clauses, covenants and agreements prohibited. Exception.

Sec. 38a-488a. Mandatory coverage for the diagnosis and treatment of mental or nervous conditions. Exceptions. Benefits payable re type of provider or facility. State's claim against proceeds. Direct reimbursement for certain covered services rendered by certain out-of-network providers.

Sec. 38a-488c. Mental health and substance use disorder benefits. Nonquantitative treatment limitations.

Sec. 38a-488d. Coverage for substance abuse services provided pursuant to court order.

Sec. 38a-490b. Coverage for hearing aids.

Sec. 38a-492e. Mandatory coverage for diabetes outpatient self-management training.

Sec. 38a-499. (Formerly Sec. 38-174v). Coverage for services of physician assistants and certain nurses.

Sec. 38a-503. (Formerly Sec. 38-174gg). Mandatory coverage for mammography, breast ultrasound and magnetic resonance imaging. Breast density information included in mammography report.

Sec. 38a-503a. Mandatory coverage for breast cancer survivors.

Sec. 38a-503b. Carriers to permit direct access to obstetrician-gynecologist.

Sec. 38a-514c. Mental health and substance use disorder benefits. Nonquantitative treatment limitations.

Sec. 38a-514d. Coverage for substance abuse services provided pursuant to court order.

Sec. 38a-516b. Coverage for hearing aids.

Sec. 38a-518e. Mandatory coverage for diabetes outpatient self-management training.

Sec. 38a-530. Mandatory coverage for mammography, breast ultrasound and magnetic resonance imaging. Breast density information included in mammography report.

Sec. 38a-530a. Mandatory coverage for breast cancer survivors.

Sec. 38a-530b. Carriers to permit direct access to obstetrician-gynecologist.

Sec. 38a-535. Mandatory coverage for preventive pediatric care and blood lead screening and risk assessment.

Sec. 38a-591d. Utilization review and benefit determinations. Urgent care requests. Information provided in notice of adverse determination.

Sec. 38a-591e. Internal grievance process of adverse determinations based on medical necessity. Expedited review of adverse determinations of urgent care requests.

Sec. 38a-591g. External reviews and expedited external reviews.


PART I

HEALTH INSURANCE: IN GENERAL

Sec. 38a-472a. Medical provider indemnification agreements prohibited. No contract between a managed care company, other organization or insurer authorized to do business in this state and a medical provider practicing in this state for the provision of services may require that the medical provider indemnify the managed care company, other organization or insurer for any expenses and liabilities including, without limitation, judgments, settlements, attorneys' fees, court costs and any associated charges incurred in connection with any claim or action brought against a managed care company, other organization or insurer on the basis of its determination of medical necessity or appropriateness of health care services if the information provided by such medical provider used in making the determination was accurate and appropriate at the time it was given. As used in this section and section 38a-472b, “medical provider” means any person licensed pursuant to chapters 370 to 373, inclusive, or chapter 375, 378, 379, 380 or 383.

(P.A. 95-199, S. 3; P.A. 15-118, S. 44; P.A. 19-98, S. 7.)

History: P.A. 15-118 made a technical change; P.A. 19-98 redefined “medical provider” by adding reference to Ch. 378.

Sec. 38a-472c. Dental policies. Estimate of reimbursement. Material adjustments to fee schedules for in-network providers. Notice. (a) For any policy delivered, issued for delivery, renewed, amended or continued in this state that provides coverage for inpatient or outpatient dental services only, the person who issues the policy shall provide the insured or a licensed dentist acting on behalf of the insured, upon request, an estimate of reimbursement under the policy with respect to specific dental procedure codes ordered or recommended for the insured by a licensed dentist, except that the actual reimbursement may be adjusted based on factors such as the insured's eligibility, plan design, utilization of benefits and the actual claim submitted.

(b) No person that issues a policy described in subsection (a) of this section that uses a provider network for such policy shall materially adjust the fee schedule for in-network providers more than once annually.

(c) Each person that makes a material adjustment described in subsection (b) of this section shall issue a notice to each in-network provider at least ninety days before the effective date of such adjustment. Each such notice shall be sent by mail, electronic mail or facsimile, and disclose:

(1) The percentage effect that such adjustment will have on such provider's fees; or

(2) A measure, other than the measure described in subdivision (1) of this subsection, that will enable such provider to understand how such adjustment will affect such provider's fees for the twenty covered procedures that such provider most frequently performed, and for which such provider sought reimbursement, during the twelve months immediately preceding the date of such notice.

(P.A. 04-125, S. 1; P.A. 11-19, S. 7; P.A. 19-155, S. 3.)

History: P.A. 11-9 made a technical change; P.A. 19-155 designated existing provisions re policy that provides coverage for inpatient or outpatient dental services only as Subsec. (a) and added Subsecs. (b) and (c) re material adjustments to fee schedules for in-network providers, effective January 1, 2020.

Sec. 38a-472h. Fees charged by dentists, optometrists and ophthalmologists for noncovered benefits. Notice and posting required. (a) No insurer, health care center, fraternal benefit society, hospital service corporation, medical service corporation or other entity delivering, issuing for delivery, renewing, amending or continuing:

(1) An individual or a group dental plan in this state shall include in any contract with a dentist licensed pursuant to chapter 379 that is entered into, renewed or amended on or after January 1, 2012, any provision that requires such dentist to accept as payment an amount set by such insurer, center, society, corporation or entity for services or procedures provided to an insured or enrollee that are not covered benefits under such insured's or enrollee's plan; or

(2) An individual or a group vision plan in this state shall include in any contract with an optometrist licensed pursuant to chapter 380 or an ophthalmologist licensed pursuant to chapter 370 that is entered into, renewed or amended on or after January 1, 2020, any provision that requires such optometrist or ophthalmologist to accept as payment an amount set by such insurer, center, society, corporation or entity for services, procedures or products provided to an insured or enrollee that are not covered benefits under such insured's or enrollee's plan.

(b) No dentist shall charge more for services or procedures that are not covered benefits than such dentist's usual and customary rate for such services or procedures, and no optometrist or ophthalmologist shall charge more for services, procedures or products that are not covered benefits than such optometrist's or ophthalmologist's usual and customary rate for such services, procedures or products.

(c) (1) Each evidence of coverage for an individual or a group dental plan shall include the following statement:

“IMPORTANT: If you opt to receive dental services or procedures that are not covered benefits under this plan, a participating dental provider may charge you his or her usual and customary rate for such services or procedures. Prior to providing you with dental services or procedures that are not covered benefits, the dental provider should provide you with a treatment plan that includes each anticipated service or procedure to be provided and the estimated cost of each such service or procedure. To fully understand your coverage, you may wish to review your evidence of coverage document.”

(2) Each evidence of coverage for an individual or a group vision plan shall include the following statement:

“IMPORTANT: If you opt to receive optometric or ophthalmologic services, procedures or products that are not covered benefits under this plan, a participating optometrist or ophthalmologist may charge you his or her usual and customary rate for such services, procedures or products. Prior to providing you with optometric or ophthalmologic services, procedures or products that are not covered benefits, the optometrist or ophthalmologist should provide you with a treatment plan that includes each anticipated service, procedure or product to be provided and the estimated cost of each such service, procedure or product. To fully understand your coverage, you may wish to review your evidence of coverage document.”

(d) Each dentist, optometrist and ophthalmologist shall post, in a conspicuous place, a notice stating that services, procedures or products, as applicable, that are not covered benefits under an insurance policy or plan might not be offered at a discounted rate.

(e) The provisions of this section shall not apply to:

(1) A self-insured plan that covers (A) dental services or procedures, or (B) optometric or ophthalmologic services, procedures or products;

(2) A contract that is incorporated in or derived from a collective bargaining agreement or in which some or all of the material terms are subject to a collective bargaining process;

(3) A contract that is derived from a multiemployer plan, as defined in Section 3 of the Employee Retirement Income Security Act of 1974, as amended from time to time; or

(4) A network of ophthalmologists or optometrists, or both, when servicing a plan or contract described in subdivision (1), (2) or (3) of this subsection.

(P.A. 11-58, S. 19; P.A. 12-145, S. 9; P.A. 15-122, S. 1; P.A. 19-201, S. 1.)

History: P.A. 11-58 effective January 1, 2012; P.A. 12-145 made a technical change in Subsec. (a), effective June 15, 2012; P.A. 15-122 amended Subsec. (a) by designating existing provision re prohibition on dental plans for noncovered benefits as Subdiv. (1) and adding Subdiv. (2) re prohibition on vision plans for noncovered benefits, amended Subsec. (b) by adding references to optometrist and making a technical change, amended Subsec. (c) by designating existing provisions re inclusion of statement in evidence of coverage re noncovered dental services or procedures as Subdiv. (1) and adding Subdiv. (2) re inclusion of statement in evidence of coverage re noncovered optometric services or procedures, amended Subsec. (d) to add reference to optometrist, and amended Subsec. (e) to add reference to optometric services, effective January 1, 2016; P.A. 19-201 added provisions re ophthalmologists and products in Subsecs. (a)(2), (b), (c)(2), (d) and (e)(1), amended Subsec. (a)(2) by substituting “2020” for “2016”, amended Subsec. (e) by adding Subdiv. (3) re multiemployer plans and adding Subdiv. (4) re networks of ophthalmologists or optometrists, and made technical changes, effective January 1, 2020.

Sec. 38a-472j. Restrictions applicable to cost-sharing for covered benefits. Regulations. (a) Notwithstanding any provision of the general statutes and to the maximum extent permitted by federal law, no individual or group health insurance policy delivered, issued for delivery, renewed, amended or continued in this state on or after January 1, 2020, providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 shall impose a coinsurance, copayment, deductible or other out-of-pocket expense for a covered benefit in an amount that exceeds the lesser of:

(1) The amount paid to the provider or vendor for the covered benefit, including all discounts, rebates and adjustments, by the insurer, health care center, fraternal benefit society, hospital service corporation, medical service corporation or other entity that delivered, issued for delivery, renewed, amended or continued such policy or an intermediary engaged by such insurer, center, society, corporation or entity;

(2) An amount calculated on the basis of the amount charged for the covered benefit by the provider or vendor, less any discount for such covered benefit and any amount due to, or charged by, an entity if such entity is affiliated with, or owned or controlled by, the insurer, health care center, fraternal benefit society, hospital service corporation, medical service corporation or other entity that delivered, issued for delivery, renewed, amended or continued such policy; or

(3) The amount that the insured would have paid to the provider or vendor for the covered benefit without regard to such policy. If the Insurance Commissioner adopts regulations pursuant to subsection (c) of this section, the commissioner may define such amount in such regulations.

(b) Any violation of subsection (a) of this section shall be deemed an unfair method of competition and unfair and deceptive act or practice in the business of insurance under section 38a-816.

(c) The Insurance Commissioner may adopt regulations, in accordance with the provisions of chapter 54, to implement the provisions of this section.

(P.A. 19-117, S. 236.)

History: P.A. 19-117 effective January 1, 2020.

Sec. 38a-472k. Disability income policies. Discretionary clauses prohibited. Regulations. No insurer, health care center, fraternal benefit society, hospital service corporation, medical service corporation or other entity delivering, issuing for delivery, renewing, amending or continuing an individual or group health insurance policy in this state on or after January 1, 2020, providing coverage of the type specified in subdivision (5) of section 38a-469 shall include in such policy a provision reserving discretion to such insurer, center, society, corporation or entity to interpret the terms of such policy, or provide standards for the interpretation or review of such policy, that are inconsistent with the laws of this state.

(P.A. 19-117, S. 244.)

History: P.A. 19-117 effective January 1, 2020.

Sec. 38a-475. Precertification of long-term care policies under the Connecticut Partnership for Long-Term Care. Regulations. The Insurance Department shall only precertify long-term care insurance policies that (1) alert the purchaser to the availability of consumer information and public education provided by the Department of Aging and Disability Services pursuant to section 17b-251; (2) offer the option of home and community-based services in addition to nursing home care; (3) in all home care plans, include case management services delivered by an access agency approved by the Office of Policy and Management and the Department of Social Services as meeting the requirements for such agency as defined in regulations adopted pursuant to subsection (e) of section 17b-342, which services shall include, but need not be limited to, the development of a comprehensive individualized assessment and care plan and, as needed, the coordination of appropriate services and the monitoring of the delivery of such services; (4) provide inflation protection; (5) provide for the keeping of records and an explanation of benefit reports on insurance payments which count toward Medicaid resource exclusion; and (6) provide the management information and reports necessary to document the extent of Medicaid resource protection offered and to evaluate the Connecticut Partnership for Long-Term Care. No policy shall be precertified if it requires prior hospitalization or a prior stay in a nursing home as a condition of providing benefits. The commissioner may adopt regulations, in accordance with chapter 54, to carry out the precertification provisions of this section.

(P.A. 89-352, S. 3, 6; P.A. 91-187, S. 3, 4; P.A. 93-262, S. 1, 87; P.A. 95-160, S. 14, 69; P.A. 96-139, S. 12, 13; P.A. 04-10, S. 14; 04-257, S. 62; P.A. 13-125, S. 26; P.A. 17-15, S. 40; June Sp. Sess. P.A. 17-2, S. 314; P.A. 18-169, S. 38; P.A. 19-157, S. 91.)

History: P.A. 91-187 amended Subdivs. (2), (3) and (4) to require all precertified policies to provide that the option of home and community-based services be offered in addition to nursing home care, that all home care plans include case management services and that all such policies provide inflation protection, deleting provision re option to furnish periodic per diem upgrades until insured begins receiving long-term care benefits; P.A. 93-262 authorized substitution of commissioner and department of social services for commissioner and department on aging, effective July 1, 1993; P.A. 95-160 replaced a reference to coordination, assessment and monitoring agencies with access agencies, effective July 1, 1995 (Revisor's note: A reference to “Department of Insurance” was replaced editorially by the Revisors with “Insurance Department” for consistency with customary statutory usage); P.A. 96-139 changed effective date of P.A. 95-160 but without affecting this section; P.A. 04-10, effective October 1, 2004, and P.A. 04-257, effective June 14, 2004, both substituted “17b-251” for “17a-307”; P.A. 13-125 replaced reference to Department of Social Services with reference to Department on Aging in Subdiv. (1), effective July 1, 2013; P.A. 17-15 made a technical change; June Sp. Sess. P.A. 17-2 replaced “Department on Aging” with “Department of Social Services” in Subdiv. (1), effective October 31, 2017; P.A. 18-169 replaced “Department of Social Services” with “Department of Rehabilitation Services” in Subdiv. (1), effective June 14, 2018; P.A. 19-157 replaced “Department of Rehabilitation Services” with “Department of Aging and Disability Services”.

Sec. 38a-476. Preexisting condition coverage. (a) For the purposes of this section:

(1) “Health insurance plan” means any hospital and medical expense incurred policy, hospital or medical service plan contract and health care center subscriber contract. “Health insurance plan” does not include (A) accident only, credit, dental, vision, Medicare supplement, long-term care or disability insurance, hospital indemnity coverage, coverage issued as a supplement to liability insurance, insurance arising out of a workers' compensation or similar law, automobile medical payments insurance, or insurance under which beneficiaries are payable without regard to fault and which is statutorily required to be contained in any liability insurance policy or equivalent self-insurance, or (B) policies of specified disease or limited benefit health insurance, provided the carrier offering such policies files on or before March first of each year a certification with the Insurance Commissioner that contains the following: (i) A statement from the carrier certifying that such policies are being offered and marketed as supplemental health insurance and not as a substitute for hospital or medical expense insurance; (ii) a summary description of each such policy including the average annual premium rates, or range of premium rates in cases where premiums vary by age, gender or other factors, charged for such policies in the state; and (iii) in the case of a policy that is described in this subparagraph and that is offered for the first time in this state on or after October 1, 1993, the carrier files with the commissioner the information and statement required in this subparagraph at least thirty days prior to the date such policy is issued or delivered in this state.

(2) “Insurance arrangement” means any “multiple employer welfare arrangement”, as defined in Section 3 of the Employee Retirement Income Security Act of 1974, as amended from time to time, except for any such arrangement that is fully insured within the meaning of Section 514(b)(6) of said act, as amended from time to time.

(3) “Preexisting conditions provision” means a policy provision that limits or excludes benefits relating to a condition based on the fact that the condition was present before the effective date of coverage, whether or not any medical advice, diagnosis, care or treatment was recommended or received before such effective date. Genetic information shall not be treated as a condition in the absence of a diagnosis of the condition related to such information. Pregnancy shall not be considered a preexisting condition.

(4) “Applicable waiting period” means the period of time imposed by the group policyholder or contractholder before an individual is eligible for participating in the group policy or contract.

(b) (1) No group health insurance plan or insurance arrangement shall impose a preexisting conditions provision on any individual.

(2) No individual health insurance plan or insurance arrangement shall impose a preexisting conditions provision on any individual.

(3) No insurance company, fraternal benefit society, hospital service corporation, medical service corporation or health care center shall refuse to issue an individual health insurance plan or insurance arrangement to any individual solely on the basis that such individual has a preexisting condition.

(P.A. 93-345, S. 3; P.A. 96-87, S. 1-3; 96-177, S. 5; June 18 Sp. Sess. P.A. 97-8, S. 65, 88; P.A. 98-27, S. 14; P.A. 00-121; P.A. 02-24, S. 5; P.A. 07-113, S. 3; P.A. 08-110, S. 2; P.A. 11-58, S. 41; P.A. 14-122, S. 49; P.A. 15-247, S. 8; P.A. 17-15, S. 41; P.A. 19-134, S. 1.)

History: P.A. 96-87 amended Subsec. (a) and added Subsec. (f) to exempt “short-term” policies which provide the prescribed disclosures, effective May 8, 1996; P.A. 96-177 redefined “preexisting conditions provision” to specify that breast cancer check-ups are not medical advice, diagnosis, care or treatment unless evidence of breast cancer is found; June 18 Sp. Sess. P.A. 97-8 redefined “preexisting conditions provision” in Subsec. (a), amended Subsec. (b) to delete references to pregnancy, to substitute “whether physical or mental” for “manifesting themselves or” in Subdiv. (1) and to substitute “whether physical or mental, which manifest themselves” for “manifesting themselves” in Subdiv. (2), amended Subsecs. (c) and (d) to substitute “less than sixty-three days” for “not more than thirty days” and to substitute “sixty-three days” for “thirty days”, added new Subsec. (e) re compliance with the Public Health Service Act, designated former Subsecs. (e) and (f) as Subsecs. (f) and (g) respectively, amending new Subsec. (f) re application dates of Subsec. (e), and added new Subsec. (h) re regulations to enforce HIPAA, effective July 1, 1997; P.A. 98-27 amended Subsec. (d) to substitute “time such individual” for “time such person” and substituted “such individual's initial eligibility” for “their initial eligibility”; P.A. 00-121 amended Subsecs. (c) and (d) by amending time periods from 63 to 120 days and 90 to 150 days, amending application deadline from 63 to 30 days, and making technical changes for purposes of gender neutrality; P.A. 02-24 substituted “their” for “its” in Subsec. (c); P.A. 07-113 amended Subsec. (b)(2) to delete reference to conditions “which manifest themselves”, amended Subsec. (g) to require a short-term health insurance policy which imposes preexisting conditions provision to be subject to conditions, including a requirement for disclosure of a statement re exclusion of coverage under the policy in a conspicuous manner, to provide for a reduction in preexisting conditions exclusion period in the second, third or subsequent policy if an insurer or health care center issues two, three or more consecutive short-term health insurance policies with preexisting conditions provision to the same individual, and to require that nothing in section be construed to require short-term health insurance policy to be issued on a guaranteed issue or guaranteed renewable basis, and amended Subsec. (h) to authorize commissioner to adopt regulations to enforce provisions of section; P.A. 08-110 changed “may” to “shall” and made technical changes in Subsec. (b), effective May 27, 2008; P.A. 11-58 amended Subsec. (b) to prohibit preexisting conditions provision that excludes coverage for individuals 18 years of age and younger in Subdivs. (1) and (2), and added Subdiv. (3) prohibiting issuance refusal of an individual health insurance plan or arrangement to such individuals solely on the basis of a preexisting condition, effective July 2, 2011; P.A. 14-122 made technical changes in Subsec. (a)(2); P.A. 15-247 amended Subsec. (a) by deleting former Subdiv. (4) re definition of “qualifying coverage” and redesignating existing Subdiv. (5) as Subdiv. (4), amended Subsec. (b) by replacing conditions for imposition of preexisting conditions provision with prohibition on such imposition in Subdivs. (1) and (2), deleted former Subsecs. (c) to (f) re coverage for preexisting conditions, redesignated existing Subsec. (g) as Subsec. (c) and amended same to designate existing provisions re short-term health insurance policy as Subdiv. (1) and existing provisions re additional short-term health insurance policies as Subdiv. (2), deleted former Subsec. (h) re adoption of regulations concerning preexisting conditions and portability, and made technical and conforming changes, effective July 10, 2015; P.A. 17-15 made a technical change in Subsec. (a)(1)(B); P.A. 19-134 amended Subsec. (a) by redefining “health insurance plan” in Subdiv.(1) and redefining “preexisting conditions provision” in Subdiv. (3), and deleted Subsec. (c) re short-term health insurance policies issued on a nonrenewable basis for 6 months or less, effective January 1, 2020.

Sec. 38a-477aa. Cost-sharing and health care provider reimbursements for emergency services and surprise bills. (a) As used in this section:

(1) “Emergency condition” has the same meaning as “emergency medical condition”, as provided in section 38a-591a;

(2) “Emergency services” means, with respect to an emergency condition, (A) a medical screening examination as required under Section 1867 of the Social Security Act, as amended from time to time, that is within the capability of a hospital emergency department, including ancillary services routinely available to such department to evaluate such condition, and (B) such further medical examinations and treatment required under said Section 1867 to stabilize such individual, that are within the capability of the hospital staff and facilities;

(3) “Health care plan” means an individual or a group health insurance policy or health benefit plan that provides coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469;

(4) “Health care provider” means an individual licensed to provide health care services under chapters 370 to 373, inclusive, chapters 375 to 383b, inclusive, and chapters 384a to 384c, inclusive;

(5) “Health carrier” means an insurance company, health care center, hospital service corporation, medical service corporation, fraternal benefit society or other entity that delivers, issues for delivery, renews, amends or continues a health care plan in this state;

(6) (A) “Surprise bill” means a bill for health care services, other than emergency services, received by an insured for services rendered by an out-of-network health care provider, where such services were rendered by (i) such out-of-network provider at an in-network facility, during a service or procedure performed by an in-network provider or during a service or procedure previously approved or authorized by the health carrier and the insured did not knowingly elect to obtain such services from such out-of-network provider, or (ii) a clinical laboratory, as defined in section 19a-30, that is an out-of-network provider, upon the referral of an in-network provider.

(B) “Surprise bill” does not include a bill for health care services received by an insured when an in-network health care provider was available to render such services and the insured knowingly elected to obtain such services from another health care provider who was out-of-network.

(b) (1) No health carrier shall require prior authorization for rendering emergency services to an insured.

(2) No health carrier shall impose, for emergency services rendered to an insured by an out-of-network health care provider, a coinsurance, copayment, deductible or other out-of-pocket expense that is greater than the coinsurance, copayment, deductible or other out-of-pocket expense that would be imposed if such emergency services were rendered by an in-network health care provider.

(3) (A) If emergency services were rendered to an insured by an out-of-network health care provider, such health care provider may bill the health carrier directly and the health carrier shall reimburse such health care provider the greatest of the following amounts: (i) The amount the insured's health care plan would pay for such services if rendered by an in-network health care provider; (ii) the usual, customary and reasonable rate for such services; or (iii) the amount Medicare would reimburse for such services. As used in this subparagraph, “usual, customary and reasonable rate” means the eightieth percentile of all charges for the particular health care service performed by a health care provider in the same or similar specialty and provided in the same geographical area, as reported in a benchmarking database maintained by a nonprofit organization specified by the Insurance Commissioner. Such organization shall not be affiliated with any health carrier.

(B) Nothing in this subdivision shall be construed to prohibit such health carrier and out-of-network health care provider from agreeing to a greater reimbursement amount.

(c) With respect to a surprise bill:

(1) An insured shall only be required to pay the applicable coinsurance, copayment, deductible or other out-of-pocket expense that would be imposed for such health care services if such services were rendered by an in-network health care provider; and

(2) A health carrier shall reimburse the out-of-network health care provider or insured, as applicable, for health care services rendered at the in-network rate under the insured's health care plan as payment in full, unless such health carrier and health care provider agree otherwise.

(d) If health care services were rendered to an insured by an out-of-network health care provider and the health carrier failed to inform such insured, if such insured was required to be informed, of the network status of such health care provider pursuant to subdivision (3) of subsection (d) of section 38a-591b, the health carrier shall not impose a coinsurance, copayment, deductible or other out-of-pocket expense that is greater than the coinsurance, copayment, deductible or other out-of-pocket expense that would be imposed if such services were rendered by an in-network health care provider.

(P.A. 15-146, S. 9; P.A. 19-117, S. 240.)

History: P.A. 15-146 effective July 1, 2016; P.A. 19-117 amended Subsec. (a)(6)(A) by redefining “surprise bill”, effective January 1, 2020.

Sec. 38a-477cc. Contracts for pharmacy services with health carriers or pharmacy benefits managers. (a) No contract for pharmacy services entered into in the state between a health carrier, as defined in section 38a-591a, or pharmacy benefits manager, as defined in section 38a-479aaa, and a pharmacy or pharmacist shall:

(1) On and after January 1, 2018, contain a provision prohibiting or penalizing, including through increased utilization review, reduced payments or other financial disincentives, a pharmacist's disclosure to an individual purchasing prescription medication of information regarding:

(A) The cost of the prescription medication to the individual; or

(B) The availability of any therapeutically equivalent alternative medications or alternative methods of purchasing the prescription medication, including, but not limited to, paying a cash price, that are less expensive than the cost of the prescription medication to the individual; and

(2) On and after January 1, 2020, contain a provision permitting the health carrier or pharmacy benefits manager to recoup, directly or indirectly, from a pharmacy or pharmacist any portion of a claim that such health carrier or pharmacy benefits manager has paid to the pharmacy or pharmacist, unless such recoupment is permitted under section 38a-479iii or required by applicable law.

(b) (1) On and after January 1, 2018, no health carrier or pharmacy benefits manager shall require an individual to make a payment at the point of sale for a covered prescription medication in an amount greater than the lesser of:

(A) The applicable copayment for such prescription medication;

(B) The allowable claim amount for the prescription medication; or

(C) The amount an individual would pay for the prescription medication if the individual purchased the prescription medication without using a health benefit plan, as defined in section 38a-591a, or any other source of prescription medication benefits or discounts.

(2) For the purposes of this subsection, “allowable claim amount” means the amount the health carrier or pharmacy benefits manager has agreed to pay the pharmacy for the prescription medication.

(c) Any provision of a contract that violates the provisions of this section shall be void and unenforceable. Any general business practice that violates the provisions of this section shall constitute an unfair trade practice pursuant to chapter 735a. The invalidity or unenforceability of any contract provision under this subsection shall not affect any other provision of the contract.

(d) The Insurance Commissioner may:

(1) Enforce the provisions of this section pursuant to chapter 697; and

(2) Upon request, audit a contract for pharmacy services for compliance with the provisions of this section.

(P.A. 17-241, S. 1; P.A. 19-199, S. 1.)

History: P.A. 19-199 amended Subsec. (a) by deleting reference to January 1, 2018, designating existing provisions re contract for pharmacy services as new Subdiv. (1) and amending same by adding reference to January 1, 2018, redesignating existing Subdiv. (1) as Subpara. (A) and redesignating existing Subdiv. (2) as Subpara. (B), and adding new Subdiv. (2) re contract for pharmacy services on and after January 1, 2020, amended Subsec. (b) by designating existing provisions re payment at point of sale for prescription medication as new Subdiv. (1), redesignating existing Subdiv. (1) as Subpara. (A), redesignating existing Subdivs. (2) and (3) as Subparas. (B) and (C), and designating existing provision defining “allowable claim amount” as Subdiv. (2), and made technical and conforming changes.

Sec. 38a-477dd. Contracts with health carriers. Certain provisions concerning disclosures to covered persons prohibited. Notwithstanding any provision of the general statutes, and to the maximum extent permitted by applicable law, no contract entered into or amended by a health carrier, as defined in section 38a-591a, on or after January 1, 2020, shall contain any provision prohibiting or penalizing, including, but not limited to, through increased utilization review, reduced payments or other financial disincentives, disclosure of any information to a covered person, as defined in section 38a-591a, concerning:

(1) The cost of a covered benefit, including, but not limited to, the cash price of a covered benefit; or

(2) The availability and cost of any health care service or product that is therapeutically equivalent to a covered benefit, including, but not limited to, the cash price of any such health care service or product.

(P.A. 19-117, S. 238.)

History: P.A. 19-117 effective January 1, 2020.

Sec. 38a-477ee. Mental health and substance use disorder benefits. Nonquantitative treatment limitations. Reports. Public hearings. Regulations. (a) For the purposes of this section:

(1) “Health carrier” has the same meaning as provided in section 38a-1080;

(2) “Mental health and substance use disorder benefits” means all benefits for the treatment of a mental health condition or a substance use disorder that (A) falls under one or more of the diagnostic categories listed in the chapter concerning mental disorders in the most recent edition of the International Classification of Diseases, or (B) is a mental disorder, as that term is defined in the most recent edition of the American Psychiatric Association's “Diagnostic and Statistical Manual of Mental Disorders”; and

(3) “Nonquantitative treatment limitation” means a limitation that cannot be expressed numerically but otherwise limits the scope or duration of a covered benefit.

(b) Not later than March 1, 2021, and annually thereafter, each health carrier shall submit a report to the Insurance Commissioner, in a form and manner prescribed by the commissioner, containing the following information for the calendar year immediately preceding:

(1) A description of the processes that such health carrier used to develop and select criteria to assess the medical necessity of (A) mental health and substance use disorder benefits, and (B) medical and surgical benefits;

(2) A description of all nonquantitative treatment limitations that such health carrier applied to (A) mental health and substance use disorder benefits, and (B) medical and surgical benefits; and

(3) The results of an analysis concerning the processes, strategies, evidentiary standards and other factors that such health carrier used in developing and applying the criteria described in subdivision (1) of this subsection and each nonquantitative treatment limitation described in subdivision (2) of this subsection, provided the commissioner shall not disclose such results in a manner that is likely to compromise the financial, competitive or proprietary nature of such results. The results of such analysis shall, at a minimum:

(A) Disclose each factor that such health carrier considered, regardless of whether such health carrier rejected such factor, in (i) designing each nonquantitative treatment limitation described in subdivision (2) of this subsection, and (ii) determining whether to apply such nonquantitative treatment limitation;

(B) Disclose any and all evidentiary standards, which standards may be qualitative or quantitative in nature, applied under a factor described in subparagraph (A) of this subdivision, and, if no evidentiary standard is applied under such a factor, a clear description of such factor;

(C) Provide the comparative analyses, including the results of such analyses, performed to determine that the processes and strategies used to design each nonquantitative treatment limitation, as written, and the processes and strategies used to apply such nonquantitative treatment limitation, as written, to mental health and substance use disorder benefits are comparable to, and applied no more stringently than, the processes and strategies used to design each nonquantitative treatment limitation, as written, and the processes and strategies used to apply such nonquantitative treatment limitation, as written, to medical and surgical benefits;

(D) Provide the comparative analyses, including the results of such analyses, performed to determine that the processes and strategies used to apply each nonquantitative treatment limitation, in operation, to mental health and substance use disorder benefits are comparable to, and applied no more stringently than, the processes and strategies used to apply each nonquantitative treatment limitation, in operation, to medical and surgical benefits; and

(E) Disclose information that, in the opinion of the Insurance Commissioner, is sufficient to demonstrate that such health carrier, consistent with the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, P.L. 110-343, as amended from time to time, and regulations adopted thereunder, (i) applied each nonquantitative treatment limitation described in subdivision (2) of this subsection comparably, and not more stringently, to (I) mental health and substance use disorder benefits, and (II) medical and surgical benefits, and (ii) complied with (I) sections 38a-488c and 38a-514c, (II) sections 38a-488a and 38a-514, (III) sections 38a-510 and 38a-544, and (IV) the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, P.L. 110-343, as amended from time to time, and regulations adopted thereunder.

(c) (1) Not later than April 15, 2021, and annually thereafter, the Insurance Commissioner shall submit each report that the commissioner received pursuant to subsection (b) of this section for the calendar year immediately preceding to:

(A) The joint standing committee of the General Assembly having cognizance of matters relating to insurance, in accordance with section 11-4a; and

(B) The Attorney General, Healthcare Advocate and executive director of the Office of Health Strategy.

(2) Notwithstanding subdivision (1) of this subsection, the commissioner shall not submit the name or identity of any health carrier or entity that has contracted with such health carrier, and such name or identity shall be given confidential treatment and not be made public by the commissioner.

(d) Not later than May 15, 2021, and annually thereafter, the joint standing committee of the General Assembly having cognizance of matters relating to insurance may hold a public hearing concerning the reports that such committee received pursuant to subsection (c) of this section for the calendar year immediately preceding. The Insurance Commissioner, or the commissioner's designee, shall attend the public hearing and inform the committee whether, in the commissioner's opinion, each health carrier, for the calendar year immediately preceding, (1) submitted a report pursuant to subsection (b) of this section that satisfies the requirements established in said subsection, and (2) complied with (A) sections 38a-488c and 38a-514c, (B) sections 38a-488a and 38a-514, (C) sections 38a-510 and 38a-544, and (D) the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, P.L. 110-343, as amended from time to time, and regulations adopted thereunder.

(e) Nothing in this section shall be construed to require any disclosure in violation of (1) 42 USC 290dd-2, as amended from time to time, (2) 42 USC 1320d et seq., as amended from time to time, (3) 42 CFR 2, as amended from time to time, and (4) 45 CFR 160.101 to 164.534, inclusive, as amended from time to time.

(f) The Insurance Commissioner may adopt regulations, in accordance with chapter 54, to implement the provisions of this section.

(P.A. 19-159, S. 1.)

PART Ia

HEALTH INSURANCE: MANAGED CARE

Sec. 38a-478j. Coinsurance and deductible payments based on negotiated discounts. Each managed care plan that requires a deductible or percentage coinsurance payment by the insured shall calculate the insured's deductible or coinsurance payment on the lesser of the provider's or vendor's charges for the goods or services or the amount payable by the managed care organization or a subcontractor of such managed care organization for such goods or services, except as otherwise required by the laws of a foreign state when applicable to providers, vendors or patients in such foreign state.

(P.A. 97-99, S. 11; June 18 Sp. Sess. P.A. 97-8, S. 59, 88; P.A. 19-117, S. 239.)

History: June 18 Sp. Sess. P.A. 97-8 added exception re laws of a foreign state, effective July 1, 1997; P.A. 19-117 added references to deductible and added “or a subcontractor of such managed care organization”, effective January 1, 2020.

Sec. 38a-478r. Emergency rooms. Prudent layperson standard. Presenting symptoms or final diagnosis as basis for coverage. Mandatory coverage for medically necessary health care services for emergency medical conditions. (a) Each provider, as defined in section 38a-478, shall code for the presenting symptoms of all emergency claims and each hospital shall record such code for such claims on locator 76 on the UB92 form or its successor.

(b) The presenting symptoms, as coded by the provider and recorded by the hospital on the UB92 form or its successor, or the final diagnosis, whichever reasonably indicates an emergency medical condition, shall be the basis for reimbursement or coverage, provided such symptoms reasonably indicated an emergency medical condition.

(c) For the purposes of this section, in accordance with the National Committee for Quality Assurance, an emergency medical condition is a condition such that a prudent layperson, acting reasonably, would have believed that emergency medical treatment is needed.

(d) The Insurance Commissioner may develop and disseminate to hospitals in this state a claims form system that will ensure that all hospitals consistently code for the presenting and diagnosis symptoms on all emergency claims.

(e) Each health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for health care services that are medically necessary, as defined in section 38a-482a or 38a-513c, as applicable, for an emergency medical condition described in subsection (c) of this section.

(P.A. 97-99, S. 26; June 18 Sp. Sess. P.A. 97-8, S. 61, 88; P.A. 11-58, S. 73; P.A. 15-118, S. 49; P.A. 19-117, S. 246.)

History: June 18 Sp. Sess. P.A. 97-8 amended Subsec. (b) to add provision re “the final diagnosis, whichever reasonably indicates an emergency medical condition,” effective July 1, 1997; P.A. 11-58 amended Subsec. (d) to delete provision re consultation with working group convened pursuant to Sec. 38a-478p, effective July 1, 2011; P.A. 15-118 made a technical change in Subsec. (c); P.A. 19-117 added Subsec. (e) re coverage for medically necessary health care services for emergency medical conditions, effective January 1, 2020.

Sec. 38a-479. Definitions. Access to fee schedules. Fee information to be confidential. (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 applicable to such provider's specialty or, upon request, current dental terminology (CDT) codes, (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.

(P.A. 06-178, S. 1; P.A. 07-54, S. 2; P.A. 09-204, S. 1; P.A. 11-132, S. 1; P.A. 19-155, S. 1.)

History: P.A. 07-54 made a technical change in Subsec. (c), effective May 22, 2007; P.A. 09-204 amended Subsec. (a) by deleting former Subdiv. (2) defining “physician” and adding new Subdiv. (2) defining “provider”, amended Subsec. (b) by revising fee schedules and other information contracting health organizations are required to provide to providers and specifying access methodology, deleted former Subsec. (c) re procedure, redesignated existing Subsecs. (d) and (e) as Subsecs. (c) and (d) and made conforming and technical changes, effective January 1, 2010; P.A. 11-132 made a technical change in Subsec. (a)(2); P.A. 19-155 amended Subsec. (a)(2) by redefining “provider” and amended Subsecs. (b)(1) and (c) by adding references to current dental terminology codes, effective January 1, 2020.

Sec. 38a-479b. Material changes to fee schedules. Return of payment by provider. Appeals. Filing of claim by provider under other applicable insurance coverage. Certain clauses, covenants and agreements prohibited. Exception. (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. 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.

(b) Notwithstanding subsection (a) of this section, a contracting health organization may introduce a new insurance product to a provider at any time, provided such provider is given at least sixty days' advance notice by mail, electronic mail or facsimile by such organization if the introduction of such insurance product will make material changes to the provider's administrative requirements under the participating provider contract or to the provider's fee schedule. The provider may decline to participate in such new product by providing notice to the contracting health organization as set forth in the advance notice, which shall include a period of not less than thirty days for a provider to decline, or in accordance with the time frames under the applicable terms of such provider's participating provider contract.

(c) (1) No contracting health organization shall cancel, deny or demand the return of full or partial payment for an authorized covered service due to administrative or eligibility error, more than eighteen months after the date of the receipt of a clean claim, except if:

(A) Such organization has a documented basis to believe that such claim was submitted fraudulently by such provider;

(B) The provider did not bill appropriately for such claim based on the documentation or evidence of what medical service was actually provided;

(C) Such organization has paid the provider for such claim more than once;

(D) Such organization paid a claim that should have been or was paid by a federal or state program; or

(E) The provider received payment for such claim from a different insurer, payor or administrator through coordination of benefits or subrogation, or due to coverage under an automobile insurance or workers' compensation policy. Such provider shall have one year after the date of the cancellation, denial or return of full or partial payment to resubmit an adjusted secondary payor claim with such organization on a secondary payor basis, regardless of such organization's timely filing requirements.

(2) (A) Such organization shall give at least thirty days' advance notice to a provider by mail, electronic mail or facsimile of the organization's cancellation, denial or demand for the return of full or partial payment pursuant to subdivision (1) of this subsection.

(B) If such organization demands the return of full or partial payment from a provider, the notice required under subparagraph (A) of this subdivision shall disclose to the provider (i) the amount that is demanded to be returned, (ii) the claim that is the subject of such demand, and (iii) the basis on which such return is being demanded.

(C) Not later than thirty days after the receipt of the notice required under subparagraph (A) of this subdivision, a provider may appeal such cancellation, denial or demand in accordance with the procedures provided by such organization. Any demand for the return of full or partial payment shall be stayed during the pendency of such appeal.

(D) If there is no appeal or an appeal is denied, such provider may resubmit an adjusted claim, if applicable, to such organization, not later than thirty days after the receipt of the notice required under subparagraph (A) of this subdivision or the denial of the appeal, whichever is applicable, except that if a return of payment was demanded pursuant to subparagraph (C) of subdivision (1) of this subsection, such claim shall not be resubmitted.

(E) A provider shall have one year after the date of the written notice set forth in subparagraph (A) of this subdivision to identify any other appropriate insurance coverage applicable on the date of service and to file a claim with such insurer, health care center or other issuing entity, regardless of such insurer's, health care center's or other issuing entity's timely filing requirements.

(d) Except as provided in subsection (e) of this section, no contracting health organization shall include in any participating provider contract or contract with a hospital licensed under chapter 368v, that is entered into, renewed or amended on or after October 1, 2011, or contract offered to a provider or hospital on or after October 1, 2011, any clause, covenant or agreement that:

(1) Requires the provider or hospital to:

(A) Disclose to the contracting health organization the provider's or hospital's payment or reimbursement rates from any other contracting health organization the provider or hospital has contracted, or may contract, with;

(B) Provide services or procedures to the contracting health organization at a payment or reimbursement rate equal to or lower than the lowest of such rates the provider or hospital has contracted, or may contract, with any other contracting health organization;

(C) Certify to the contracting health organization that the provider or hospital has not contracted with any other contracting health organization to provide services or procedures at a payment or reimbursement rate lower than the rates contracted for with the contracting health organization;

(2) Prohibits or limits the provider or hospital from contracting with any other contracting health organization to provide services or procedures at a payment or reimbursement rate lower than the rates contracted for with the contracting health organization; or

(3) Allows the contracting health organization to terminate or renegotiate a contract with the provider or hospital prior to renewal if the provider or hospital contracts with any other contracting health organization to provide services or procedures at a lower payment or reimbursement rate than the rates contracted for with the contracting health organization.

(e) (1) If a contract described in subsection (d) of this section is in effect prior to October 1, 2011, and includes a clause, covenant or agreement set forth under subdivisions (1) to (3), inclusive, of said subsection (d), such clause, covenant or agreement shall be void and unenforceable on the date such contract is next renewed or on January 1, 2014, whichever is earlier. Such invalidity shall not affect other provisions of such contract.

(2) Nothing in subdivision (1) of this subsection shall be construed to affect the rights of a contracting health organization to enforce such clause, covenant or agreement prior to the invalidation of such clause, covenant or agreement.

(P.A. 09-204, S. 2; P.A. 11-58, S. 16; 11-132, S. 2; P.A. 19-155, S. 2.)

History: P.A. 09-204 effective July 1, 2010; P.A. 11-58 added new Subsec. (b) re introduction of new insurance products, and redesignated existing Subsec. (b) as Subsec. (c), effective January 1, 2012; P.A. 11-132 added provisions, codified by the Revisors as Subsec. (d), prohibiting certain clauses, covenants or agreements in contracts between contracting health organizations and health care providers and hospitals, and added provisions, codified by the Revisors as Subsec. (e), re exception; P.A. 19-155 amended Subsec. (d) by deleting references to dentists, effective January 1, 2020.

PART II

INDIVIDUAL HEALTH INSURANCE

Sec. 38a-488a. Mandatory coverage for the diagnosis and treatment of mental or nervous conditions. Exceptions. Benefits payable re type of provider or facility. State's claim against proceeds. Direct reimbursement for certain covered services rendered by certain out-of-network providers. (a) For the purposes of this section: (1) “Mental or nervous conditions” means mental disorders, as defined in the most recent edition of the American Psychiatric Association's “Diagnostic and Statistical Manual of Mental Disorders”. “Mental or nervous conditions” does not include (A) intellectual disability, (B) specific learning disorders, (C) motor disorders, (D) communication disorders, (E) caffeine-related disorders, (F) relational problems, and (G) other conditions that may be a focus of clinical attention, that are not otherwise defined as mental disorders in the most recent edition of the American Psychiatric Association's “Diagnostic and Statistical Manual of Mental Disorders”; (2) “benefits payable” means the usual, customary and reasonable charges for treatment deemed necessary under generally accepted medical standards, except that in the case of a managed care plan, as defined in section 38a-478, “benefits payable” means the payments agreed upon in the contract between a managed care organization, as defined in section 38a-478, and a provider, as defined in section 38a-478; (3) “acute treatment services” means twenty-four-hour medically supervised treatment for a substance use disorder, that is provided in a medically managed or medically monitored inpatient facility; and (4) “clinical stabilization services” means twenty-four-hour clinically managed postdetoxification treatment, including, but not limited to, relapse prevention, family outreach, aftercare planning and addiction education and counseling.

(b) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide benefits for the diagnosis and treatment of mental or nervous conditions. Benefits payable include, but need not be limited to:

(1) General inpatient hospitalization, including in state-operated facilities;

(2) Medically necessary acute treatment services and medically necessary clinical stabilization services;

(3) General hospital outpatient services, including at state-operated facilities;

(4) Psychiatric inpatient hospitalization, including in state-operated facilities;

(5) Psychiatric outpatient hospital services, including at state-operated facilities;

(6) Intensive outpatient services, including at state-operated facilities;

(7) Partial hospitalization, including at state-operated facilities;

(8) Intensive, home-based services designed to address specific mental or nervous conditions in a child;

(9) Evidence-based family-focused therapy that specializes in the treatment of juvenile substance use disorders;

(10) Short-term family therapy intervention;

(11) Nonhospital inpatient detoxification;

(12) Medically monitored detoxification;

(13) Ambulatory detoxification;

(14) Inpatient services at psychiatric residential treatment facilities;

(15) Rehabilitation services provided in residential treatment facilities, general hospitals, psychiatric hospitals or psychiatric facilities;

(16) Observation beds in acute hospital settings;

(17) Psychological and neuropsychological testing conducted by an appropriately licensed health care provider;

(18) Trauma screening conducted by a licensed behavioral health professional;

(19) Depression screening, including maternal depression screening, conducted by a licensed behavioral health professional;

(20) Substance use screening conducted by a licensed behavioral health professional;

(c) No such policy shall establish any terms, conditions or benefits that place a greater financial burden on an insured for access to diagnosis or treatment of mental or nervous conditions than for diagnosis or treatment of medical, surgical or other physical health conditions, or prohibit an insured from obtaining or a health care provider from being reimbursed for multiple screening services as part of a single-day visit to a health care provider or a multicare institution, as defined in section 19a-490.

(d) In the case of benefits payable for the services of a licensed physician, such benefits shall be payable for the same services when such services are lawfully rendered by a psychologist licensed under the provisions of chapter 383 or by such a licensed psychologist in a licensed hospital or clinic or an advanced practice registered nurse licensed under the provisions of chapter 378.

(e) In the case of benefits payable for the services of a licensed physician or psychologist, such benefits shall be payable for the same services when such services are rendered by:

(1) A clinical social worker who is licensed under the provisions of chapter 383b and who has passed the clinical examination of the American Association of State Social Work Boards and has completed at least two thousand hours of post-master's social work experience in a nonprofit agency qualifying as a tax-exempt organization under Section 501(c) of the Internal Revenue Code of 1986 or any subsequent corresponding internal revenue code of the United States, as from time to time amended, in a municipal, state or federal agency or in an institution licensed by the Department of Public Health under section 19a-490;

(2) A social worker who was certified as an independent social worker under the provisions of chapter 383b prior to October 1, 1990;

(3) A licensed marital and family therapist who has completed at least two thousand hours of post-master's marriage and family therapy work experience in a nonprofit agency qualifying as a tax-exempt organization under Section 501(c) of the Internal Revenue Code of 1986 or any subsequent corresponding internal revenue code of the United States, as from time to time amended, in a municipal, state or federal agency or in an institution licensed by the Department of Public Health under section 19a-490;

(4) A marital and family therapist who was certified under the provisions of chapter 383a prior to October 1, 1992;

(5) A licensed alcohol and drug counselor, as defined in section 20-74s, or a certified alcohol and drug counselor, as defined in section 20-74s;

(6) A licensed professional counselor; or

(7) An advanced practice registered nurse licensed under the provisions of chapter 378.

(f) (1) In the case of benefits payable for the services of a licensed physician, such benefits shall be payable for (A) services rendered in a child guidance clinic or residential treatment facility by a person with a master's degree in social work or by a person with a master's degree in marriage and family therapy under the supervision of a psychiatrist, physician, licensed marital and family therapist, or licensed clinical social worker who is eligible for reimbursement under subdivisions (1) to (4), inclusive, of subsection (e) of this section; (B) services rendered in a residential treatment facility by a licensed or certified alcohol and drug counselor who is eligible for reimbursement under subdivision (5) of subsection (e) of this section; (C) services rendered in a residential treatment facility by a licensed professional counselor who is eligible for reimbursement under subdivision (6) of subsection (e) of this section; or (D) services rendered in a residential treatment facility by a licensed advanced practice registered nurse who is eligible for reimbursement under subdivision (7) of subsection (e) of this section.

(2) In the case of benefits payable for the services of a licensed psychologist under subsection (e) of this section, such benefits shall be payable for (A) services rendered in a child guidance clinic or residential treatment facility by a person with a master's degree in social work or by a person with a master's degree in marriage and family therapy under the supervision of such licensed psychologist, licensed marital and family therapist, or licensed clinical social worker who is eligible for reimbursement under subdivisions (1) to (4), inclusive, of subsection (e) of this section; (B) services rendered in a residential treatment facility by a licensed or certified alcohol and drug counselor who is eligible for reimbursement under subdivision (5) of subsection (e) of this section; (C) services rendered in a residential treatment facility by a licensed professional counselor who is eligible for reimbursement under subdivision (6) of subsection (e) of this section; or (D) services rendered in a residential treatment facility by a licensed advanced practice registered nurse who is eligible for reimbursement under subdivision (7) of subsection (e) of this section.

(g) In the case of benefits payable for the service of a licensed physician practicing as a psychiatrist or a licensed psychologist, under subsection (e) of this section, such benefits shall be payable for outpatient services rendered (1) in a nonprofit community mental health center, as defined by the Department of Mental Health and Addiction Services, in a nonprofit licensed adult psychiatric clinic operated by an accredited hospital or in a residential treatment facility; (2) under the supervision of a licensed physician practicing as a psychiatrist, a licensed psychologist, a licensed marital and family therapist, a licensed clinical social worker, a licensed or certified alcohol and drug counselor, a licensed professional counselor or a licensed advanced practice registered nurse who is eligible for reimbursement under subdivisions (1) to (7), inclusive, of subsection (e) of this section; and (3) within the scope of the license issued to the center or clinic by the Department of Public Health or to the residential treatment facility by the Department of Children and Families.

(h) Except in the case of emergency services or in the case of services for which an individual has been referred by a physician or an advanced practice registered nurse affiliated with a health care center, nothing in this section shall be construed to require a health care center to provide benefits under this section through facilities that are not affiliated with the health care center.

(i) In the case of any person admitted to a state institution or facility administered by the Department of Mental Health and Addiction Services, Department of Public Health, Department of Children and Families or the Department of Developmental Services, the state shall have a lien upon the proceeds of any coverage available to such person or a legally liable relative of such person under the terms of this section, to the extent of the per capita cost of such person's care. Except in the case of emergency services, the provisions of this subsection shall not apply to coverage provided under a managed care plan, as defined in section 38a-478.

(j) Reimbursement for covered services rendered in this state by an out-of-network health care provider for the diagnosis or treatment of a substance use disorder shall be paid under the insured's individual health insurance policy directly to the provider if the provider is otherwise eligible for reimbursement for such services. The insured who received such services shall be deemed to have made an assignment to such provider of such insured's coverage reimbursement benefits and other rights under the policy. In no event shall such provider bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from or have any recourse against the insured for such services, except that such provider may collect any copayments, deductibles or other out-of-pocket expenses that the insured is required to pay under the policy.

(June 18 Sp. Sess. P.A. 97-8, S. 63, 88; P.A. 99-284, S. 27, 60; P.A. 00-135, S. 10, 21; P.A. 02-24, S. 6; P.A. 07-73, S. 2(a); P.A. 12-145, S. 45; P.A. 13-84, S. 3; 13-139, S. 33; P.A. 14-235, S. 57; P.A. 15-226, S. 1; June Sp. Sess. P.A. 15-5, S. 43, 44; P.A. 17-9, S. 3; 17-157, S. 1; June Sp. Sess. P.A. 17-2, S. 202; P.A. 18-68, S. 10; P.A. 19-98, S. 8.)

History: June 18 Sp. Sess. P.A. 97-8 effective July 1, 1997; P.A. 99-284 rewrote Subsec. (a) and referenced Subdivs. (1), (2), (4), (11) and (12) of Sec. 38a-469, deleted reference to biologically-based mental or nervous conditions and definition thereof and replaced with provision for coverage of the diagnosis and treatment of mental or nervous conditions, and defined “mental or nervous conditions”, added new Subsec. (b) re prohibition on terms, conditions or benefits that place a greater financial burden on insured re mental or nervous conditions than for other conditions, added new Subsec. (c) re benefits payable when rendered by a psychologist, added new Subsec. (d) re benefits payable for enumerated providers, added new Subsec. (e) to define “covered expenses”, added new Subsec. (f) re benefits payable for services rendered in certain facilities, added new Subsec. (g) re certain outpatient benefits, added new Subsec. (h) re benefits provided by a health care center, and added new Subsec. (i) re state liens against certain coverage proceeds, effective January 1, 2000; P.A. 00-135 reorganized section and added provisions re licensed professional counselors, effective May 26, 2000; P.A. 02-24 deleted “the” re “post-master's social work experience” in Subsec. (d)(1) and (3); pursuant to P.A. 07-73 “Department of Mental Retardation” was changed editorially by the Revisors to “Department of Developmental Services”, effective October 1, 2007; P.A. 12-145 amended Subsec. (a) to delete “on or after January 1, 2000”, effective June 15, 2012; P.A. 13-84 amended Subsec. (a) by adding provision re coverage for insured diagnosed with autism spectrum disorder prior to release of the fifth edition of the American Psychiatric Association's “Diagnostic and Statistical Manual of Mental Disorders”, effective June 5, 2013; P.A. 13-139 amended Subsec. (a)(1) by substituting “intellectual disability” for “mental retardation”; P.A. 14-235 amended Subsec. (a) to replace “disability” with “disabilities” in Subdiv. (1), add “specific” in Subdiv. (2), delete “skills” in Subdiv. (3) and replace “additional” with “other” in Subdiv. (7); P.A. 15-226 amended Subsec. (a) by deleting provisions re insurance policy and coverage for insured diagnosed with autism spectrum disorder prior to release of 5th edition of American Psychiatric Association's “Diagnostic and Statistical Manual of Mental Disorders”, adding definitions of “benefits payable”, “acute treatment services” and “clinical stabilization services”, and making technical changes, added new Subsec. (b) re coverage requirements, redesignated existing Subsec. (b) as Subsec. (c) and amended same by adding provision re policy not to prohibit insured from obtaining or health care provider from being reimbursed for multiple screening services, redesignated existing Subsec. (c) as Subsec. (d), redesignated existing Subsec. (d) as Subsec. (e) and amended same by adding Subdiv. (7) re advanced practice registered nurse, deleted former Subsec. (e) re definition of “covered expenses”, and made conforming changes in Subsecs. (f) and (g), effective January 1, 2016; June Sp. Sess. P.A. 15-5 amended Subsec. (b) by deleting reference to problematic parenting practices and other family and educational challenges in Subdiv. (9), deleting former Subdiv. (10) re coverage for intensive, family-based and community-based treatment programs, redesignating existing Subdiv. (11) as Subdiv. (10) and amending same to delete “and delinquency”, redesignating existing Subdiv. (12) as Subdiv. (11) and amending same to delete provision re juvenile diversion programs, deleting former Subdivs. (13), (14) and (19) re coverage for other home-based therapeutic interventions for children, chemical maintenance treatment and extended day treatment programs, and redesignating existing Subdivs. (15) to (18) and (20) to (25) as Subdivs. (12) to (21), effective January 1, 2016, and further amended Subsec. (b) by adding Subdivs. (22) to (25) re coverage for intensive, family-based and community-based treatment programs, other home-based therapeutic interventions for children, chemical maintenance treatment and extended day treatment programs, effective January 1, 2017; P.A. 17-9 amended Subsec. (a)(1)(A) by replacing “disabilities” with “disability”; P.A. 17-157 added Subsec. (j) re reimbursement to out-of-network health care provider for diagnosis or treatment of substance use disorder, effective January 1, 2018; June Sp. Sess. P.A. 17-2 amended Subsec. (b) by deleting former Subdiv. (8) re maternal, infant and early childhood home visitation services, redesignating existing Subdivs. (9) to (21) as Subdivs. (8) to (20) and deleting former Subdivs. (22) to (25) re intensive, family-based and community-based treatment programs, other home-based therapeutic interventions for children, chemical maintenance treatment and extended day treatment programs, respectively, effective October 31, 2017; P.A. 18-68 made a technical change in Subsec. (e)(7); P.A. 19-98 amended Subsecs. (d), (g)(2) and (h) by adding references to advanced practice registered nurse, amended Subsecs. (f)(1) and (f)(2) by adding Subpara. (D) re services rendered in residential treatment facility by an advanced practice registered nurse and made technical and conforming changes.

Sec. 38a-488c. Mental health and substance use disorder benefits. Nonquantitative treatment limitations. No individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state on or after January 1, 2020, shall apply a nonquantitative treatment limitation to mental health and substance use disorder benefits unless such policy applies such limitation to such benefits in a manner that is comparable to, and not more stringent than, the manner in which such policy applies such limitation to medical and surgical benefits. For the purposes of this section, “nonquantitative treatment limitation” and “mental health and substance use disorder benefits” have the same meaning as provided in section 38a-477ee.

(P.A. 19-159, S. 2.)

History: P.A. 19-159 effective January 1, 2020.

Sec. 38a-488d. Coverage for substance abuse services provided pursuant to court order. No individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 that is delivered, issued for delivery, renewed, amended or continued in this state on or after January 1, 2020, shall deny coverage for covered substance abuse services solely because such substance abuse services were provided pursuant to an order issued by a court of competent jurisdiction.

(P.A. 19-159, S. 4.)

History: P.A. 19-159 effective January 1, 2020.

Sec. 38a-490b. Coverage for hearing aids. Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for hearing aids. Such hearing aids shall be considered durable medical equipment under the policy and the policy may limit the hearing aid benefit to one hearing aid per ear within a twenty-four-month period.

(P.A. 01-171, S. 15; P.A. 12-145, S. 47; P.A. 19-133, S. 1.)

History: P.A. 12-145 deleted “on or after October 1, 2001”, effective June 15, 2012; P.A. 19-133 deleted reference to children 12 years of age or younger and substituted provision restricting benefit to 1 hearing aid per ear within 24-month period for provision restricting benefit to $1,000 within 24-month period, effective January 1, 2020.

Sec. 38a-492e. Mandatory coverage for diabetes outpatient self-management training. (a) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed or continued in this state shall provide coverage for outpatient self-management training for the treatment of insulin-dependent diabetes, insulin-using diabetes, gestational diabetes and non-insulin-using diabetes if the training is prescribed by a licensed health care professional who has appropriate state licensing authority to prescribe such training. As used in this section, “outpatient self-management training” includes, but is not limited to, education and medical nutrition therapy. Diabetes self-management training shall be provided by a certified, registered or licensed health care professional trained in the care and management of diabetes and authorized to provide such care within the scope of the professional's practice.

(b) Benefits shall cover: (1) Initial training visits provided to an individual after the individual is initially diagnosed with diabetes that is medically necessary for the care and management of diabetes, including, but not limited to, counseling in nutrition and the proper use of equipment and supplies for the treatment of diabetes, totaling a maximum of ten hours; (2) training and education that is medically necessary as a result of a subsequent diagnosis by a physician or an advanced practice registered nurse of a significant change in the individual's symptoms or condition which requires modification of the individual's program of self-management of diabetes, totaling a maximum of four hours; and (3) training and education that is medically necessary because of the development of new techniques and treatment for diabetes totaling a maximum of four hours.

(c) Benefits provided pursuant to this section shall be subject to the same terms and conditions applicable to all other benefits under such policies.

(P.A. 99-284, S. 43, 60; P.A. 17-15, S. 52; P.A. 19-98, S. 9.)

History: P.A. 99-284 effective January 1, 2000; P.A. 17-15 amended Subsec. (a) to delete reference to January 1, 2000; P.A. 19-98 amended Subsec. (b) by adding “or an advanced practice registered nurse”.

Sec. 38a-499. (Formerly Sec. 38-174v). Coverage for services of physician assistants and certain nurses. (a) For the purposes of this section:

(1) “Advanced practice registered nurse” means any advanced practice registered nurse licensed under the provisions of chapter 378;

(2) “Certified psychiatric-mental health advanced practice registered nurse” means any advanced practice registered nurse licensed under chapter 378 who is board certified as a psychiatric-mental health provider by the American Nurses Credentialing Center;

(3) “Certified nurse-midwife” means any individual certified as nurse-midwife pursuant to sections 20-86a to 20-86e, inclusive;

(4) “Physician assistant” means an individual licensed pursuant to section 20-12b.

(b) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for the services of physician assistants, advanced practice registered nurses, certified psychiatric-mental health advanced practice registered nurses and certified nurse-midwives if such services are within the individual's area of professional competence as established by education and licensure or certification and are currently reimbursed when rendered by any other licensed health care provider. Subject to the provisions of chapter 378 and sections 20-86a to 20-86e, inclusive, no insurer, hospital service corporation, medical service corporation or health care center may require signature, referral or employment by any other health care provider as a condition of reimbursement, provided no insurer, hospital service corporation, medical service corporation or health care center may be required to pay for duplicative services actually rendered by both a physician assistant or an advanced practice registered nurse and any other health care provider. The payment of such benefits shall be subject to any policy provisions which apply to other licensed health practitioners providing the same services. Nothing in this section may be construed as permitting (1) any registered nurse to perform or provide services beyond the scope of practice permitted in chapter 378 and sections 20-86a to 20-86e, inclusive, or (2) any physician assistant to perform or provide services beyond the scope of practice permitted in chapter 370.

(P.A. 84-231; P.A. 90-243, S. 89; P.A. 95-74, S. 7, 9; P.A. 11-19, S. 47; P.A. 19-98, S. 10.)

History: P.A. 90-243 substituted references to “health insurance policy” for references to hospital and medical expense policies and contracts, applied provisions to health care centers and specified applicability solely to individual policies; Sec. 38-174v transferred to Sec. 38a-499 in 1991; P.A. 95-74 added physician assistants to those whose services must be included in coverage and defined “physician assistant”, effective July 1, 1995; P.A. 11-19 inserted “amended or continued” and made technical changes in Subsec. (b), effective January 1, 2012; P.A. 19-98 amended Subsec. (a) by replacing “certified nurse practitioner” with “advanced practice registered nurse” and replacing provisions defining “certified nurse practitioner” with provisions defining “advanced practice registered nurse” in Subdiv. (1), replacing “certified psychiatric-mental health clinical nurse specialist” with “certified psychiatric-mental health advanced practice registered nurse” and replacing provisions defining “certified psychiatric-mental health clinical nurse specialist” with provisions defining “certified psychiatric-mental health advanced practice registered nurse” in Subdiv. (2), amended Subsec. (b) by replacing references to certified nurse practitioners, clinical nurse specialists and certified registered nurses with references to advanced practice registered nurses, and made technical and conforming changes.

Sec. 38a-503. (Formerly Sec. 38-174gg). Mandatory coverage for mammography, breast ultrasound and magnetic resonance imaging. Breast density information included in mammography report. (a) For purposes of this section:

(1) “Healthcare Common Procedure Coding System” or “HCPCS” means the billing codes used by Medicare and overseen by the federal Centers for Medicare and Medicaid Services that are based on the current procedural technology codes developed by the American Medical Association; and

(2) “Mammogram” means mammographic examination or breast tomosynthesis, including, but not limited to, a procedure with a HCPCS code of 77051, 77052, 77055, 77056, 77057, 77063, 77065, 77066, 77067, G0202, G0204, G0206 or G0279, or any subsequent corresponding code.

(b) (1) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (10), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide benefits for mammograms to any woman covered under the policy that are at least equal to the following minimum requirements: (A) A baseline mammogram, which may be provided by breast tomosynthesis at the option of the woman covered under the policy, for any woman who is thirty-five to thirty-nine years of age, inclusive; and (B) a mammogram, which may be provided by breast tomosynthesis at the option of the woman covered under the policy, every year for any woman who is forty years of age or older.

(2) Such policy shall provide additional benefits for:

(A) Comprehensive ultrasound screening of an entire breast or breasts if: (i) A mammogram demonstrates heterogeneous or dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology; (ii) a woman is believed to be at increased risk for breast cancer due to (I) family history or prior personal history of breast cancer, (II) positive genetic testing, or (III) other indications as determined by a woman's physician or advanced practice registered nurse; or (iii) such screening is recommended by a woman's treating physician for a woman who (I) is forty years of age or older, (II) has a family history or prior personal history of breast cancer, or (III) has a prior personal history of breast disease diagnosed through biopsy as benign; and

(B) Magnetic resonance imaging of an entire breast or breasts in accordance with guidelines established by the American Cancer Society.

(c) Benefits under this section shall be subject to any policy provisions that apply to other services covered by such policy, except that no such policy shall impose a coinsurance, copayment, deductible or other out-of-pocket expense for such benefits. The provisions of this subsection shall apply to a high deductible plan, as that term is used in subsection (f) of section 38a-493, to the maximum extent permitted by federal law, except if such plan is used to establish a medical savings account or an Archer MSA pursuant to Section 220 of the Internal Revenue Code of 1986 or any subsequent corresponding internal revenue code of the United States, as amended from time to time, or a health savings account pursuant to Section 223 of said Internal Revenue Code, as amended from time to time, the provisions of this subsection shall apply to such plan to the maximum extent that (1) is permitted by federal law, and (2) does not disqualify such account for the deduction allowed under said Section 220 or 223, as applicable.

(d) Each mammography report provided to a patient shall include information about breast density, based on the Breast Imaging Reporting and Data System established by the American College of Radiology. Where applicable, such report shall include the following notice: “If your mammogram demonstrates that you have dense breast tissue, which could hide small abnormalities, you might benefit from supplementary screening tests, which can include a breast ultrasound screening or a breast MRI examination, or both, depending on your individual risk factors. A report of your mammography results, which contains information about your breast density, has been sent to your physician's or advanced practice registered nurse's office and you should contact your physician or advanced practice registered nurse if you have any questions or concerns about this report.”.

(P.A. 88-124, S. 1; P.A. 90-243, S. 93; P.A. 01-171, S. 22; P.A. 05-69, S. 1; P.A. 06-38, S. 1; P.A. 09-41, S. 1; P.A. 11-67, S. 1; 11-171, S. 1; P.A. 12-150, S. 1; P.A. 14-97, S. 1; P.A. 16-82, S. 1; P.A. 18-159, S. 1; P.A. 19-98, S. 11; 19-117, S. 209.)

History: P.A. 90-243 substituted reference to health insurance policies for references to hospital or medical expense policies and contracts and specified applicability solely to individual policies; Sec. 38-174gg transferred to Sec. 38a-503 in 1991; P.A. 01-171 added “amended or continued” re policies in this state, substituted “October 1, 2001,” for “October 1, 1988,” re policy date, consolidated Subdivs. (2) and (3) to provide annual coverage for any woman who is forty or over rather than coverage every two years for women 40 to 49 and annually thereafter, and substituted “each” for “every”; P.A. 05-69 added Subsec. designators (a) and (b), amended Subsec. (a) to require benefits for comprehensive ultrasound screening for certain women if recommended by a physician, and made technical changes in Subsec. (b); P.A. 06-38 amended Subsec. (a) to require policy to provide additional benefits for comprehensive ultrasound screening of an entire breast or breasts if mammogram demonstrates heterogeneous or dense breast tissue based on the BIRAD System or if a woman is believed to be at increased risk for breast cancer due to family history or prior personal history of breast cancer, positive genetic testing or other indications determined by a physician or advanced practice registered nurse, eliminating reference to screening recommended by a physician for a woman classified as a category 2, 3, 4 or 5 under such system; P.A. 09-41 added Subsec. (c) re breast density information required to be provided to a patient and notice where applicable; P.A. 11-67 amended Subsec. (a) to add mandatory coverage for magnetic resonance imaging if a mammogram demonstrates heterogeneous or dense breast tissue or if a woman is believed to be at increased risk for breast cancer due to family or prior personal history, and to make technical changes, effective January 1, 2012; P.A. 11-171 amended Subsec. (a) to add mandatory coverage for magnetic resonance imaging in accordance with guidelines established by the American Cancer Society or the American College of Radiology, and to make technical changes, effective January 1, 2012; P.A. 12-150 amended Subsec. (a)(2) to delete “and magnetic resonance imaging” in Subpara. (A) and add “of an entire breast or breasts” and delete reference to American College of Radiology in Subpara. (B), amended Subsec. (c) to delete “On and after October 1, 2009”, and made technical changes, effective June 15, 2012; P.A. 14-97 amended Subsec. (b) to add provision limiting copayment for breast ultrasound screening to maximum of $20, effective January 1, 2015; P.A. 16-82 amended Subsec. (a)(1) by adding “, which may be provided by breast tomosynthesis at the option of the woman covered under the policy,” in Subparas. (A) and (B), effective January 1, 2017; P.A. 18-159 added new Subsec. (a) defining “Healthcare Common Procedure Coding System” and “Mammogram”, redesignated existing Subsecs. (a) to (c) as Subsecs. (b) to (d), and made conforming changes, effective January 1, 2019; P.A. 19-98 amended Subsec. (d) to add references to advanced practice registered nurse; P.A. 19-117 amended Subsec. (b)(2)(A) by designating existing provisions re heterogeneous or dense breast tissue as Subpara. (A)(i), designating existing provisions re women believed to be at increased risk for breast cancer as Subpara. (A)(ii) and adding Subpara. (A)(iii) re screening recommended by woman's treating physician, and amended Subsec. (c) by deleting provision re maximum of $20 for ultrasound screening and adding provisions prohibiting coinsurances, copayments, deductibles, out-of-pocket expenses and concerning high deductible plans, effective January 1, 2020.

Sec. 38a-503a. Mandatory coverage for breast cancer survivors. Section 38a-503 is repealed, effective January 1, 2020.

(P.A. 96-177, S. 4; P.A. 17-15, S. 57; P.A. 19-134, S. 2.)

Sec. 38a-503b. Carriers to permit direct access to obstetrician-gynecologist. (a) As used in this section, “carrier” means each insurer, health care center, hospital service corporation, medical service corporation or other entity delivering, issuing for delivery, renewing, amending or continuing any individual health insurance policy in this state providing coverage of the type specified in subdivisions (1), (2), (4), (10), (11) and (12) of section 38a-469.

(b) Each carrier shall permit a female enrollee direct access to a participating in-network obstetrician-gynecologist for any gynecological examination or care related to pregnancy and shall allow direct access to a participating in-network obstetrician-gynecologist for primary and preventive obstetric and gynecologic services required as a result of any gynecological examination or as a result of a gynecological condition. Such obstetric and gynecologic services include, but are not limited to, pap smear tests. The plan may require the participating in-network obstetrician-gynecologist to discuss such services and any treatment plan with the female enrollee's primary care provider. Nothing in this section shall preclude access to an in-network nurse-midwife as licensed pursuant to sections 20-86c and 20-86g and in-network advanced practice registered nurses as licensed pursuant to sections 20-93 and 20-94a for obstetrical and gynecological services within their scope of practice.

(c) Each carrier may allow a female enrollee to designate either a participating, in-network obstetrician-gynecologist or any other in-network physician designated by the carrier as a primary care provider, or both, and may offer the same choice to all female enrollees.

(P.A. 95-199, S. 1; P.A. 96-227, S. 14; P.A. 01-171, S. 18; P.A. 10-32, S. 120; P.A. 11-19, S. 49; P.A. 14-122, S. 50; P.A. 19-125, S. 10.)

History: P.A. 96-227 amended Subsec. (a) to include Subdiv. (12) in its citation to Sec. 38a-469; P.A. 01-171 amended Subsec. (b) to provide that “such obstetric and gynecologic services include, but are not limited to, pap smear tests”; P.A. 10-32 made a technical change in Subsec. (b), effective May 10, 2010; P.A. 11-19 inserted “or continuing” and made technical changes in Subsec. (a), effective January 1, 2012; P.A. 14-122 made a technical change in Subsec. (b); P.A. 19-125 amended Subsec. (a) to redefine “carrier”, effective January 1, 2020.

PART III

GROUP HEALTH INSURANCE

Sec. 38a-514c. Mental health and substance use disorder benefits. Nonquantitative treatment limitations. No group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state on or after January 1, 2020, shall apply a nonquantitative treatment limitation to mental health and substance use disorder benefits unless such policy applies such limitation to such benefits in a manner that is comparable to, and not more stringent than, the manner in which such policy applies such limitation to medical and surgical benefits. For the purposes of this section, “nonquantitative treatment limitation” and “mental health and substance use disorder benefits” have the same meaning as provided in section 38a-477ee.

(P.A. 19-159, S. 3.)

History: P.A. 19-159 effective January 1, 2020.

Sec. 38a-514d. Coverage for substance abuse services provided pursuant to court order. No group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 that is delivered, issued for delivery, renewed, amended or continued in this state on or after January 1, 2020, shall deny coverage for covered substance abuse services solely because such substance abuse services were provided pursuant to an order issued by a court of competent jurisdiction.

(P.A. 19-159, S. 5.)

History: P.A. 19-159 effective January 1, 2020.

Sec. 38a-516b. Coverage for hearing aids. Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for hearing aids. Such hearing aids shall be considered durable medical equipment under the policy and the policy may limit the hearing aid benefit to one hearing aid per ear within a twenty-four-month period.

(P.A. 01-171, S. 16; P.A. 12-145, S. 48; P.A. 19-133, S. 2.)

History: P.A. 12-145 deleted “on or after October 1, 2001”, effective June 15, 2012; P.A. 19-133 deleted reference to children 12 years of age or younger and substituted provision restricting benefit to 1 hearing aid per ear within 24 month period for provision restricting benefit to $1,000 within 24-month period, effective January 1, 2020.

Sec. 38a-518e. Mandatory coverage for diabetes outpatient self-management training. (a) Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed or continued in this state shall provide coverage for outpatient self-management training for the treatment of insulin-dependent diabetes, insulin-using diabetes, gestational diabetes and non-insulin-using diabetes if the training is prescribed by a licensed health care professional who has appropriate state licensing authority to prescribe such training. As used in this section, “outpatient self-management training” includes, but is not limited to, education and medical nutrition therapy. Diabetes self-management training shall be provided by a certified, registered or licensed health care professional trained in the care and management of diabetes and authorized to provide such care within the scope of the professional's practice.

(b) Benefits shall cover: (1) Initial training visits provided to an individual after the individual is initially diagnosed with diabetes that is medically necessary for the care and management of diabetes, including, but not limited to, counseling in nutrition and the proper use of equipment and supplies for the treatment of diabetes, totaling a maximum of ten hours; (2) training and education that is medically necessary as a result of a subsequent diagnosis by a physician or advanced practice registered nurse of a significant change in the individual's symptoms or condition which requires modification of the individual's program of self-management of diabetes, totaling a maximum of four hours; and (3) training and education that is medically necessary because of the development of new techniques and treatment for diabetes totaling a maximum of four hours.

(c) Benefits provided pursuant to this section shall be subject to the same terms and conditions applicable to all other benefits under such policies.

(P.A. 99-284, S. 44, 60; P.A. 17-15, S. 62; P.A. 19-98, S. 12.)

History: P.A. 99-284 effective January 1, 2000; P.A. 17-15 deleted “on or after January 1, 2000,” in Subsec. (a); P.A. 19-98 amended Subsec. (b)(2) by adding “or advanced practice registered nurse”.

Sec. 38a-530. Mandatory coverage for mammography, breast ultrasound and magnetic resonance imaging. Breast density information included in mammography report. (a) For purposes of this section:

(1) “Healthcare Common Procedure Coding System” or “HCPCS” means the billing codes used by Medicare and overseen by the federal Centers for Medicare and Medicaid Services that are based on the current procedural technology codes developed by the American Medical Association; and

(2) “Mammogram” means mammographic examination or breast tomosynthesis, including, but not limited to, a procedure with a HCPCS code of 77051, 77052, 77055, 77056, 77057, 77063, 77065, 77066, 77067, G0202, G0204, G0206 or G0279, or any subsequent corresponding code.

(b) (1) Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide benefits for mammograms to any woman covered under the policy that are at least equal to the following minimum requirements: (A) A baseline mammogram, which may be provided by breast tomosynthesis at the option of the woman covered under the policy, for any woman who is thirty-five to thirty-nine years of age, inclusive; and (B) a mammogram, which may be provided by breast tomosynthesis at the option of the woman covered under the policy, every year for any woman who is forty years of age or older.

(2) Such policy shall provide additional benefits for:

(A) Comprehensive ultrasound screening of an entire breast or breasts if: (i) A mammogram demonstrates heterogeneous or dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology; (ii) a woman is believed to be at increased risk for breast cancer due to (I) family history or prior personal history of breast cancer, (II) positive genetic testing, or (III) other indications as determined by a woman's physician or advanced practice registered nurse; or (iii) such screening is recommended by a woman's treating physician for a woman who (I) is forty years of age or older, (II) has a family history or prior personal history of breast cancer, or (III) has a prior personal history of breast disease diagnosed through biopsy as benign; and

(B) Magnetic resonance imaging of an entire breast or breasts in accordance with guidelines established by the American Cancer Society.

(c) Benefits under this section shall be subject to any policy provisions that apply to other services covered by such policy, except that no such policy shall impose a coinsurance, copayment, deductible or other out-of-pocket expense for such benefits. The provisions of this subsection shall apply to a high deductible plan, as that term is used in subsection (f) of section 38a-520, to the maximum extent permitted by federal law, except if such plan is used to establish a medical savings account or an Archer MSA pursuant to Section 220 of the Internal Revenue Code of 1986 or any subsequent corresponding internal revenue code of the United States, as amended from time to time, or a health savings account pursuant to Section 223 of said Internal Revenue Code, as amended from time to time, the provisions of this subsection shall apply to such plan to the maximum extent that (1) is permitted by federal law, and (2) does not disqualify such account for the deduction allowed under said Section 220 or 223, as applicable.

(d) Each mammography report provided to a patient shall include information about breast density, based on the Breast Imaging Reporting and Data System established by the American College of Radiology. Where applicable, such report shall include the following notice: “If your mammogram demonstrates that you have dense breast tissue, which could hide small abnormalities, you might benefit from supplementary screening tests, which can include a breast ultrasound screening or a breast MRI examination, or both, depending on your individual risk factors. A report of your mammography results, which contains information about your breast density, has been sent to your physician's or advanced practice registered nurse's office and you should contact your physician or advanced practice registered nurse if you have any questions or concerns about this report.”.

(P.A. 90-243, S. 114; P.A. 01-171, S. 23; P.A. 05-69, S. 2; P.A. 06-38, S. 2; P.A. 09-41, S. 2; P.A. 11-67, S. 2; 11-171, S. 2; P.A. 12-150, S. 2; P.A. 14-97, S. 2; P.A. 16-82, S. 2; P.A. 18-159, S. 2; P.A. 19-98, S. 13; 19-117, S. 210.)

History: P.A. 01-171 added “amended or continued” re policies in this state, substituted “October 1, 2001,” for “October 1, 1988,” re policy date, and consolidated Subdivs. (2) and (3) to provide annual coverage for any woman who is forty or over rather than coverage every two years for women 40 to 49 and annually thereafter; P.A. 05-69 added Subsec. designators (a) and (b), amended Subsec. (a) to require comprehensive ultrasound screening for certain women if recommended by a physician, and made technical changes in Subsec. (b); P.A. 06-38 amended Subsec. (a) to require policy to provide additional benefits for comprehensive ultrasound screening of an entire breast or breasts if mammogram demonstrates heterogeneous or dense breast tissue based on the BIRAD System or if a woman is believed to be at increased risk for breast cancer due to family history or prior personal history of breast cancer, positive genetic testing or other indications determined by a physician or advanced practice registered nurse, eliminating reference to screening recommended by a physician for a woman classified as a category 2, 3, 4 or 5 under such system; P.A. 09-41 added Subsec. (c) re breast density information required to be provided to a patient and notice where applicable; P.A. 11-67 amended Subsec. (a) to add mandatory coverage for magnetic resonance imaging if a mammogram demonstrates heterogeneous or dense breast tissue or if a woman is believed to be at increased risk for breast cancer due to family or prior personal history, and to make technical changes, effective January 1, 2012; P.A. 11-171 amended Subsec. (a) to add mandatory coverage for magnetic resonance imaging in accordance with guidelines established by the American Cancer Society or the American College of Radiology, and to make technical changes, effective January 1, 2012; P.A. 12-150 amended Subsec. (a)(2) to delete “and magnetic resonance imaging” in Subpara. (A) and add “of an entire breast or breasts” and delete reference to American College of Radiology in Subpara. (B), amended Subsec. (c) to delete “On and after October 1, 2009”, and made technical changes, effective June 15, 2012; P.A. 14-97 amended Subsec. (b) to add provision limiting copayment for breast ultrasound screening to maximum of $20, effective January 1, 2015; P.A. 16-82 amended Subsec. (a)(1) by adding “, which may be provided by breast tomosynthesis at the option of the woman covered under the policy,” in Subparas. (A) and (B), effective January 1, 2017; P.A. 18-159 added new Subsec. (a) defining “Healthcare Common Procedure Coding System” and “Mammogram”, redesignated existing Subsecs. (a) to (c) as Subsecs. (b) to (d), and made conforming changes, effective January 1, 2019; P.A. 19-98 amended Subsec. (d) by adding references to advanced practice registered nurses; P.A. 19-117 amended Subsec. (b)(2)(A) by designating existing provisions re heterogeneous or dense breast tissue as Subpara. (A)(i), designating existing provisions re women believed to be at increased risk for breast cancer as Subpara. (A)(ii) and adding Subpara. (A)(iii) re screening recommended by woman's treating physician, and amended Subsec. (c) by deleting provision re maximum of $20 for ultrasound screening and adding provisions prohibiting coinsurances, copayments, deductibles, out-of-pocket expenses and high deductible plans, effective January 1, 2020.

Sec. 38a-530a. Mandatory coverage for breast cancer survivors. Section 38a-530a is repealed, effective January 1, 2020.

(P.A. 96-177, S. 3; P.A. 17-15, S. 68; P.A. 19-134, S. 3.)

Sec. 38a-530b. Carriers to permit direct access to obstetrician-gynecologist. (a) As used in this section, “carrier” means each insurer, health care center, hospital service corporation, medical service corporation or other entity delivering, issuing for delivery, renewing, amending or continuing any group health insurance policy in this state providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469.

(b) Each carrier shall permit a female enrollee direct access to a participating in-network obstetrician-gynecologist for any gynecological examination or care related to pregnancy and shall allow direct access to a participating in-network obstetrician-gynecologist for primary and preventive obstetric and gynecologic services required as a result of any gynecological examination or as a result of a gynecological condition. Such obstetric and gynecologic services include, but are not limited to, pap smear tests. The plan may require the participating in-network obstetrician-gynecologist to discuss such services and any treatment plan with the female enrollee's primary care provider. Nothing in this section shall preclude access to an in-network nurse-midwife as licensed pursuant to sections 20-86c and 20-86g and in-network advanced practice registered nurses as licensed pursuant to sections 20-93 and 20-94a for obstetrical and gynecological services within their scope of practice.

(c) Each carrier may allow a female enrollee to designate either a participating, in-network obstetrician-gynecologist or any other in-network physician designated by the carrier as a primary care provider, or both, and may offer the same choice to all female enrollees.

(P.A. 95-199, S. 2; P.A. 96-227, S. 15; P.A. 01-171, S. 19; P.A. 10-32, S. 121; P.A. 11-19, S. 50; P.A. 14-122, S. 51; P.A. 19-125, S. 11.)

History: P.A. 96-227 amended Subsec. (a) to include Subdiv. (12) in its citation to Sec. 38a-469; P.A. 01-171 amended Subsec. (b) to provide that “such obstetric and gynecologic services include, but are not limited to, pap smear tests”; P.A. 10-32 made a technical change in Subsec. (b), effective May 10, 2010; P.A. 11-19 inserted “or continuing” and made technical changes in Subsec. (a), effective January 1, 2012; P.A. 14-122 made a technical change in Subsec. (b); P.A. 19-125 amended Subsec. (a) to redefine “carrier”, effective January 1, 2020.

Sec. 38a-535. Mandatory coverage for preventive pediatric care and blood lead screening and risk assessment. (a) For purposes of this section, “preventive pediatric care” means the periodic review of a child's physical and emotional health from birth through six years of age by or under the supervision of a physician. Such review shall include a medical history, complete physical examination, developmental assessment, anticipatory guidance, appropriate immunizations and laboratory tests in keeping with prevailing medical standards.

(b) Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery or renewed on or after October 1, 1989, or continued as defined in section 38a-531, on or after October 1, 1990, shall provide benefits for preventive pediatric care for any child covered by the policy or contract at approximately the following age intervals: Every two months from birth to six months of age, every three months from nine to eighteen months of age and annually from two through six years of age. Any such policy may provide that services rendered during a periodic review shall be covered to the extent that such services are provided by or under the supervision of a single physician during the course of one visit. On and after January 1, 2009, each such policy shall also provide coverage for blood lead screening and risk assessments ordered by a primary care provider pursuant to section 19a-111g. Such benefits shall be subject to any policy provisions which apply to other services covered by such policy.

(P.A. 89-101; P.A. 90-20, S. 2; 90-243, S. 178; P.A. 91-407, S. 6, 42; June Sp. Sess. P.A. 07-2, S. 52; P.A. 19-125, S. 12.)

History: P.A. 90-20 made technical changes in Subsec. (a) and amended Subsec. (b) to require mandatory benefits for preventive pediatric care policies which are continued on or after October 1, 1990; P.A. 90-243 deleted the references to “group hospital or medical expense insurance policy” and “group hospital or medical service plan contract” and inserted “health insurance policy”, made technical corrections for statutory consistency and deleted the reference to “contract”; P.A. 91-407 amended Subsec. (b) by changing “two to six years” to “two through six years”; June Sp. Sess. P.A. 07-2 amended Subsec. (b) to mandate coverage for blood lead screening and risk assessments ordered by a primary care provider under Sec. 19a-111g and to make a technical change, effective January 1, 2009; P.A. 19-125 amended Subsec. (b) to delete reference to Sec. 38a-469(6), effective January 1, 2020.

PART VII

GRIEVANCES AND EXTERNAL REVIEWS

Sec. 38a-591d. Utilization review and benefit determinations. Urgent care requests. Information provided in notice of adverse determination. (a)(1) Each health carrier shall maintain written procedures for (A) utilization review and benefit determinations, (B) expedited utilization review and benefit determinations with respect to prospective urgent care requests and concurrent review urgent care requests, and (C) notifying covered persons or covered persons' authorized representatives of such review and benefit determinations. Each health carrier shall make such review and benefit determinations within the specified time periods under this section.

(2) In determining whether a benefit request shall be considered an urgent care request, an individual acting on behalf of a health carrier shall apply the judgment of a prudent layperson who possesses an average knowledge of health and medicine, except that any benefit request (A) determined to be an urgent care request by a health care professional with knowledge of the covered person's medical condition, or (B) specified under subparagraph (B) or (C) of subdivision (38) of section 38a-591a shall be deemed an urgent care request.

(3) (A) At the time a health carrier notifies a covered person, a covered person's authorized representative or a covered person's health care professional of an initial adverse determination that was based, in whole or in part, on medical necessity, of a concurrent or prospective utilization review or of a benefit request, the health carrier shall notify the covered person's health care professional (i) of the opportunity for a conference as provided in subparagraph (B) of this subdivision, and (ii) that such conference shall not be considered a grievance of such initial adverse determination as long as a grievance has not been filed as set forth in subparagraph (B) of this subdivision.

(B) After a health carrier notifies a covered person, a covered person's authorized representative or a covered person's health care professional of an initial adverse determination that was based, in whole or in part, on medical necessity, of a concurrent or prospective utilization review or of a benefit request, the health carrier shall offer a covered person's health care professional the opportunity to confer, at the request of the covered person's health care professional, with a clinical peer of such health carrier, provided such covered person, covered person's authorized representative or covered person's health care professional has not filed a grievance of such initial adverse determination prior to such conference. Such conference shall not be considered a grievance of such initial adverse determination.

(b) With respect to a nonurgent care request:

(1) (A) For a prospective or concurrent review request, a health carrier shall make a determination within a reasonable period of time appropriate to the covered person's medical condition, but not later than fifteen calendar days after the date the health carrier receives such request, and shall notify the covered person and, if applicable, the covered person's authorized representative of such determination, whether or not the carrier certifies the provision of the benefit.

(B) If the review under subparagraph (A) of this subdivision is a review of a grievance involving a concurrent review request, pursuant to 45 CFR 147.136, as amended from time to time, the treatment shall be continued without liability to the covered person until the covered person has been notified of the review decision.

(2) For a retrospective review request, a health carrier shall make a determination within a reasonable period of time, but not later than thirty calendar days after the date the health carrier receives such request.

(3) The time periods specified in subdivisions (1) and (2) of this subsection may be extended once by the health carrier for up to fifteen calendar days, provided the health carrier:

(A) Determines that an extension is necessary due to circumstances beyond the health carrier's control; and

(B) Notifies the covered person and, if applicable, the covered person's authorized representative prior to the expiration of the initial time period, of the circumstances requiring the extension of time and the date by which the health carrier expects to make a determination.

(4) (A) If the extension pursuant to subdivision (3) of this subsection is necessary due to the failure of the covered person or the covered person's authorized representative to provide information necessary to make a determination on the request, the health carrier shall:

(i) Specifically describe in the notice of extension the required information necessary to complete the request; and

(ii) Provide the covered person and, if applicable, the covered person's authorized representative with not less than forty-five calendar days after the date of receipt of the notice to provide the specified information.

(B) If the covered person or the covered person's authorized representative fails to submit the specified information before the end of the period of the extension, the health carrier may deny certification of the benefit requested.

(c) With respect to an urgent care request:

(1) (A) Unless the covered person or the covered person's authorized representative has failed to provide information necessary for the health carrier to make a determination and except as specified under subparagraph (B) of this subdivision, the health carrier shall make a determination as soon as possible, taking into account the covered person's medical condition, but not later than forty-eight hours after the health carrier receives such request or seventy-two hours after such health carrier receives such request if any portion of such forty-eight-hour period falls on a weekend, provided, if the urgent care request is a concurrent review request to extend a course of treatment beyond the initial period of time or the number of treatments, such request is made at least twenty-four hours prior to the expiration of the prescribed period of time or number of treatments.

(B) Unless the covered person or the covered person's authorized representative has failed to provide information necessary for the health carrier to make a determination, for an urgent care request specified under subparagraph (B) or (C) of subdivision (38) of section 38a-591a, the health carrier shall make a determination as soon as possible, taking into account the covered person's medical condition, but not later than twenty-four hours after the health carrier receives such request, provided, if the urgent care request is a concurrent review request to extend a course of treatment beyond the initial period of time or the number of treatments, such request is made at least twenty-four hours prior to the expiration of the prescribed period of time or number of treatments.

(2) (A) If the covered person or the covered person's authorized representative has failed to provide information necessary for the health carrier to make a determination, the health carrier shall notify the covered person or the covered person's representative, as applicable, as soon as possible, but not later than twenty-four hours after the health carrier receives such request.

(B) The health carrier shall provide the covered person or the covered person's authorized representative, as applicable, a reasonable period of time to submit the specified information, taking into account the covered person's medical condition, but not less than forty-eight hours after notifying the covered person or the covered person's authorized representative, as applicable.

(3) The health carrier shall notify the covered person and, if applicable, the covered person's authorized representative of its determination as soon as possible, but not later than forty-eight hours after the earlier of (A) the date on which the covered person and the covered person's authorized representative, as applicable, provides the specified information to the health carrier, or (B) the date on which the specified information was to have been submitted.

(d) (1) Whenever a health carrier receives a review request from a covered person or a covered person's authorized representative that fails to meet the health carrier's filing procedures, the health carrier shall notify the covered person and, if applicable, the covered person's authorized representative of such failure not later than five calendar days after the health carrier receives such request, except that for an urgent care request, the health carrier shall notify the covered person and, if applicable, the covered person's authorized representative of such failure not later than twenty-four hours after the health carrier receives such request.

(2) If the health carrier provides such notice orally, the health carrier shall provide confirmation in writing to the covered person and the covered person's health care professional of record not later than five calendar days after providing the oral notice.

(e) Each health carrier shall provide promptly to a covered person and, if applicable, the covered person's authorized representative a notice of an adverse determination.

(1) Such notice may be provided in writing or by electronic means and shall set forth, in a manner calculated to be understood by the covered person or the covered person's authorized representative:

(A) Information sufficient to identify the benefit request or claim involved, including the date of service, if applicable, the health care professional and the claim amount;

(B) The specific reason or reasons for the adverse determination, including, upon request, a listing of the relevant clinical review criteria, including professional criteria and medical or scientific evidence and a description of the health carrier's standard, if any, that were used in reaching the denial;

(C) Reference to the specific health benefit plan provisions on which the determination is based;

(D) A description of any additional material or information necessary for the covered person to perfect the benefit request or claim, including an explanation of why the material or information is necessary to perfect the request or claim;

(E) A description of the health carrier's internal grievance process that includes (i) the health carrier's expedited review procedures, (ii) any time limits applicable to such process or procedures, (iii) the contact information for the organizational unit designated to coordinate the review on behalf of the health carrier, and (iv) a statement that the covered person or, if applicable, the covered person's authorized representative is entitled, pursuant to the requirements of the health carrier's internal grievance process, to receive from the health carrier, free of charge upon request, reasonable access to and copies of all documents, records, communications and other information and evidence regarding the covered person's benefit request;

(F) (i) (I) A copy of the specific rule, guideline, protocol or other similar criterion the health carrier relied upon to make the adverse determination, or (II) a statement that a specific rule, guideline, protocol or other similar criterion of the health carrier was relied upon to make the adverse determination and that a copy of such rule, guideline, protocol or other similar criterion will be provided to the covered person free of charge upon request, with instructions for requesting such copy, and (ii) the links to such rule, guideline, protocol or other similar criterion on such health carrier's Internet web site;

(G) If the adverse determination is based on medical necessity or an experimental or investigational treatment or similar exclusion or limit, the written statement of the scientific or clinical rationale for the adverse determination and (i) an explanation of the scientific or clinical rationale used to make the determination that applies the terms of the health benefit plan to the covered person's medical circumstances or (ii) a statement that an explanation will be provided to the covered person free of charge upon request, and instructions for requesting a copy of such explanation;

(H) A statement explaining the right of the covered person to contact the commissioner's office or the Office of the Healthcare Advocate at any time for assistance or, upon completion of the health carrier's internal grievance process, to file a civil action in a court of competent jurisdiction. Such statement shall include the contact information for said offices; and

(I) A statement that if the covered person or the covered person's authorized representative chooses to file a grievance of an adverse determination, (i) such appeals are sometimes successful, (ii) such covered person or covered person's authorized representative may benefit from free assistance from the Office of the Healthcare Advocate, which can assist such covered person or covered person's authorized representative with the filing of a grievance pursuant to 42 USC 300gg-93, as amended from time to time, (iii) such covered person or covered person's authorized representative is entitled and encouraged to submit supporting documentation for the health carrier's consideration during the review of an adverse determination, including narratives from such covered person or covered person's authorized representative and letters and treatment notes from such covered person's health care professional, and (iv) such covered person or covered person's authorized representative has the right to ask such covered person's health care professional for such letters or treatment notes.

(2) Upon request pursuant to subparagraph (E) of subdivision (1) of this subsection, the health carrier shall provide such copies in accordance with subsection (a) of section 38a-591n.

(f) If the adverse determination is a rescission, the health carrier shall include with the advance notice of the application for rescission required to be sent to the covered person, a written statement that includes:

(1) Clear identification of the alleged fraudulent act, practice or omission or the intentional misrepresentation of material fact;

(2) An explanation as to why the act, practice or omission was fraudulent or was an intentional misrepresentation of a material fact;

(3) A disclosure that the covered person or the covered person's authorized representative may file immediately, without waiting for the date such advance notice of the proposed rescission ends, a grievance with the health carrier to request a review of the adverse determination to rescind coverage, pursuant to sections 38a-591e and 38a-591f;

(4) A description of the health carrier's grievance procedures established under sections 38a-591e and 38a-591f, including any time limits applicable to those procedures; and

(5) The date such advance notice of the proposed rescission ends and the date back to which the coverage will be retroactively rescinded.

(g) (1) Whenever a health carrier fails to strictly adhere to the requirements of this section with respect to making utilization review and benefit determinations of a benefit request or claim, the covered person shall be deemed to have exhausted the internal grievance process of such health carrier and may file a request for an external review in accordance with the provisions of section 38a-591g, regardless of whether the health carrier asserts it substantially complied with the requirements of this section or that any error it committed was de minimis.

(2) A covered person who has exhausted the internal grievance process of a health carrier may, in addition to filing a request for an external review, pursue any available remedies under state or federal law on the basis that the health carrier failed to provide a reasonable internal grievance process that would yield a decision on the merits of the claim.

(P.A. 11-58, S. 57; P.A. 12-102, S. 1; P.A. 13-3, S. 73; P.A. 14-40, S. 3; P.A. 15-118, S. 54; 15-139, S. 1; P.A. 16-175, S. 2; P.A. 19-117, S. 241.)

History: P.A. 11-58 effective July 1, 2011; P.A. 12-102 amended Subsec. (e) to designate provisions re adverse determination notice as new Subdiv. (1), redesignate existing Subdivs. (1) to (8) as Subparas. (A) to (H) and make conforming changes, add “communications” and “evidence regarding” re benefit request in redesignated Subdiv. (1)(E), and add new Subdiv. (2) re health carrier obligation to provide copies in accordance with Sec. 38a-591n(a); P.A. 13-3 amended Subsec. (a) by adding reference to Sec. 38a-591a(38)(B) or (C) in Subdiv. (2) and adding Subdiv. (3) re conference opportunity offer, amended Subsec. (b) by designating existing Subdiv. (1) as Subdiv. (1)(A) and adding Subdiv. (1)(B) re continuation of treatment during review of a grievance, amended Subsec. (c) by designating existing Subdiv. (1) as Subdiv. (1)(A) and making a conforming change therein, and adding Subdiv. (1)(B) re 24-hour determination period for urgent care requests for substance use or mental disorder treatment, and amended Subsec. (e)(1) by adding clinical review criteria to information required to be provided to a covered person with an adverse determination notice in Subpara. (B), deleting provision re submission of written comments, documents, records and other material in Subpara. (E), adding provision re Internet web site links in Subpara. (F), and adding Subpara. (I) re statement specifying additional assistance information to be provided to a covered person with an adverse determination notice; P.A. 14-40 amended Subsec. (e)(1)(I) to delete reference to Division of Consumer Affairs within Insurance Department, effective May 28, 2014; P.A. 15-118 made a technical change in Subsec. (e)(1)(H); P.A. 15-139 amended Subsec. (a)(3) by adding Subpara. (A) re notification of clinical peer conference, designating existing provisions re clinical peer conference as Subpara. (B) and amending same to change such conference from optional to mandatory at the request of covered person's health care professional and make conforming changes; P.A. 16-175 amended Subsec. (e)(1)(F) by replacing “If the adverse determination is based on a health carrier's internal rule, guideline, protocol or other similar criterion, (i) the specific rule, guideline, protocol or other similar criterion, or (ii)(I)” with “(i)(I) A copy of the specific rule, guideline, protocol or other similar criterion the health carrier relied upon to make the adverse determination, or (II)”, designating existing provisions re statement and Internet links as clauses (i)(II) and (ii), respectively, deleting provision re notice of adverse determination involving treatment of substance use disorder or mental disorder, and making conforming changes, effective January 1, 2017; P.A. 19-117 amended Subsec. (c)(1)(A) by substituting “forty-eight hours” for “seventy-two hours” and adding “or seventy-two hours after such health carrier receives such request if any portion of such forty-eight-hour period falls on a weekend”, effective January 1, 2020.

Sec. 38a-591e. Internal grievance process of adverse determinations based on medical necessity. Expedited review of adverse determinations of urgent care requests. (a)(1) Each health carrier shall establish and maintain written procedures for (A) the review of grievances of adverse determinations that were based, in whole or in part, on medical necessity, (B) the expedited review of grievances of adverse determinations of urgent care requests, including concurrent review urgent care requests involving an admission, availability of care, continued stay or health care service for a covered person who has received emergency services but has not been discharged from a facility, and (C) notifying covered persons or covered persons' authorized representatives of such adverse determinations.

(2) Each health carrier shall file with the commissioner a copy of such procedures, including all forms used to process requests, and any subsequent material modifications to such procedures.

(3) In addition to a copy of such procedures, each health carrier shall file annually with the commissioner, in a form prescribed by the commissioner, a certificate of compliance stating that the health carrier has established and maintains grievance procedures for each of its health benefit plans that are fully compliant with the provisions of sections 38a-591a to 38a-591n, inclusive.

(b) (1) A covered person or a covered person's authorized representative may file a grievance of an adverse determination that was based, in whole or in part, on medical necessity with the health carrier not later than one hundred eighty calendar days after the covered person or the covered person's authorized representative, as applicable, receives the notice of an adverse determination.

(2) For prospective or concurrent urgent care requests, a covered person or a covered person's authorized representative may make a request for an expedited review orally or in writing.

(c) (1) (A) When conducting a review of an adverse determination under this section, the health carrier shall ensure that such review is conducted in a manner to ensure the independence and impartiality of the clinical peer or peers involved in making the review decision.

(B) If the adverse determination involves utilization review, the health carrier shall designate an appropriate clinical peer or peers to review such adverse determination. Such clinical peer or peers shall not have been involved in the initial adverse determination.

(C) The clinical peer or peers conducting a review under this section shall take into consideration all comments, documents, records and other information relevant to the covered person's benefit request that is the subject of the adverse determination under review, that are submitted by the covered person or the covered person's authorized representative, regardless of whether such information was submitted or considered in making the initial adverse determination.

(D) Prior to issuing a decision, the health carrier shall provide free of charge, by facsimile, electronic means or any other expeditious method available, to the covered person or the covered person's authorized representative, as applicable, any new or additional documents, communications, information and evidence relied upon and any new or additional scientific or clinical rationale used by the health carrier in connection with the grievance. Such documents, communications, information, evidence and rationale shall be provided sufficiently in advance of the date the health carrier is required to issue a decision to permit the covered person or the covered person's authorized representative, as applicable, a reasonable opportunity to respond prior to such date.

(2) If the review under subdivision (1) of this subsection is an expedited review, all necessary information, including the health carrier's decision, shall be transmitted between the health carrier and the covered person or the covered person's authorized representative, as applicable, by telephone, facsimile, electronic means or any other expeditious method available.

(3) If the review under subdivision (1) of this subsection is an expedited review of a grievance involving an adverse determination of a concurrent review request, pursuant to 45 CFR 147.136, as amended from time to time, the treatment shall be continued without liability to the covered person until the covered person has been notified of the review decision.

(d) (1) The health carrier shall notify the covered person and, if applicable, the covered person's authorized representative, in writing or by electronic means, of its decision within a reasonable period of time appropriate to the covered person's medical condition, but not later than:

(A) For prospective review and concurrent review requests, thirty calendar days after the health carrier receives the grievance;

(B) For retrospective review requests, sixty calendar days after the health carrier receives the grievance;

(C) For expedited review requests, except as specified under subparagraph (D) of this subdivision, forty-eight hours after the health carrier receives the grievance or seventy-two hours after such health carrier receives such grievance if any portion of such forty-eight-hour period falls on a weekend; and

(D) For expedited review requests of a health care service or course of treatment specified under subparagraph (B) or (C) of subdivision (38) of section 38a-591a, twenty-four hours after the health carrier receives the grievance.

(2) The time periods set forth in subdivision (1) of this subsection shall apply regardless of whether all of the information necessary to make a decision accompanies the filing.

(e) (1) The notice required under subsection (d) of this section shall set forth, in a manner calculated to be understood by the covered person or the covered person's authorized representative:

(A) The titles and qualifying credentials of the clinical peer or peers participating in the review process;

(B) Information sufficient to identify the claim involved with respect to the grievance, including the date of service, if applicable, the health care professional and the claim amount;

(C) A statement of such clinical peer's or peers' understanding of the covered person's grievance;

(D) The clinical peer's or peers' decision in clear terms and the health benefit plan contract basis or scientific or clinical rationale for such decision in sufficient detail for the covered person to respond further to the health carrier's position;

(E) Reference to the evidence or documentation used as the basis for the decision;

(F) For a decision that upholds the adverse determination:

(i) The specific reason or reasons for the final adverse determination, including the denial code and its corresponding meaning, as well as a description of the health carrier's standard, if any, that was used in reaching the denial;

(ii) Reference to the specific health benefit plan provisions on which the decision is based;

(iii) A statement that the covered person may receive from the health carrier, free of charge and upon request, reasonable access to and copies of, all documents, records, communications and other information and evidence not previously provided regarding the adverse determination under review;

(iv) If the final adverse determination is based on a health carrier's internal rule, guideline, protocol or other similar criterion, (I) the specific rule, guideline, protocol or other similar criterion, or (II) a statement that a specific rule, guideline, protocol or other similar criterion of the health carrier was relied upon to make the final adverse determination and that a copy of such rule, guideline, protocol or other similar criterion will be provided to the covered person free of charge upon request and instructions for requesting such copy;

(v) If the final adverse determination is based on medical necessity or an experimental or investigational treatment or similar exclusion or limit, the written statement of the scientific or clinical rationale for the final adverse determination and (I) an explanation of the scientific or clinical rationale used to make the determination that applies the terms of the health benefit plan to the covered person's medical circumstances, or (II) a statement that an explanation will be provided to the covered person free of charge upon request and instructions for requesting a copy of such explanation;

(vi) A statement describing the procedures for obtaining an external review of the final adverse determination;

(G) If applicable, the following statement: “You and your plan may have other voluntary alternative dispute resolution options such as mediation. One way to find out what may be available is to contact your state Insurance Commissioner.”; and

(H) A statement disclosing the covered person's right to contact the commissioner's office or the Office of the Healthcare Advocate at any time. Such disclosure shall include the contact information for said offices.

(2) Upon request pursuant to subparagraph (F)(iii) of subdivision (1) of this subsection, the health carrier shall provide such copies in accordance with subsection (b) of section 38a-591n.

(f) (1) Whenever a health carrier fails to strictly adhere to the requirements of this section with respect to receiving and resolving grievances involving an adverse determination, the covered person shall be deemed to have exhausted the internal grievance process of such health carrier and may file a request for an external review, regardless of whether the health carrier asserts that it substantially complied with the requirements of this section, or that any error it committed was de minimis.

(2) A covered person who has exhausted the internal grievance process of a health carrier may, in addition to filing a request for an external review, pursue any available remedies under state or federal law on the basis that the health carrier failed to provide a reasonable internal grievance process that would yield a decision on the merits of the claim.

(P.A. 11-58, S. 58; P.A. 12-102, S. 2; P.A. 13-3, S. 74; P.A. 16-213, S. 18; P.A. 19-117, S. 242.)

History: P.A. 11-58 effective July 1, 2011; P.A. 12-102 amended Subsec. (a)(3) to replace reference to Sec. 38a-591m with reference to Sec. 38a-591n, amended Subsec. (c)(1)(D) to add provision re methods by which health carrier is to provide copies and add “documents, communications, information” re materials health carrier is required to provide, amended Subsec. (e) to redesignate existing provisions as new Subdiv. (1), redesignate existing Subdivs. (1) to (8) as Subparas. (A) to (H) and make conforming changes, add “communications” and “evidence not previously provided regarding” and delete “relevant to” re adverse determination in redesignated Subdiv. (1)(F)(iii), and add new Subdiv. (2) re health carrier obligation to provide copies in accordance with Sec. 38a-591n(b); P.A. 13-3 amended Subsec. (c) by replacing “individual or individuals” with “clinical peer or peers” in Subdiv. (1)(A) and (C), adding reference to 45 CFR 147.136 in Subdiv. (3) and making same applicable to all concurrent review requests, rather than concurrent review urgent care requests, amended Subsec. (d)(1) by adding Subpara. (D) re 24-hour notification period for expedited review requests for substance use or mental disorder treatment, amended Subsec. (e)(1) by replacing references to individual or individuals with references to clinical peer or peers in Subparas. (A), (C) and (D), and made technical and conforming changes; P.A. 16-213 amended Subsec. (a)(3) by replacing “as part of its annual report required under subsection (e) of section 38a-591b” with “in a form prescribed by the commissioner”, effective July 1, 2016; P.A. 19-117 amended Subsec. (d)(1)(C) by substituting “forty-eight hours” for “seventy-two hours” and adding “or seventy-two hours after such health carrier receives such grievance if any portion of such forty-eight-hour period falls on a weekend”, effective January 1, 2020.

Sec. 38a-591g. External reviews and expedited external reviews. (a)(1) A covered person or a covered person's authorized representative may file a request for an external review or an expedited external review of an adverse determination or a final adverse determination in accordance with the provisions of this section. All requests for external review or expedited external review shall be made in writing to the commissioner. The commissioner may prescribe the form and content of such requests.

(2) (A) All requests for external review or expedited external review shall be accompanied by a filing fee of twenty-five dollars, except that no covered person or covered person's authorized representative shall pay more than seventy-five dollars in a calendar year for such covered person. Any filing fee paid by a covered person's authorized representative shall be deemed to have been paid by the covered person. If the commissioner finds that the covered person is indigent or unable to pay the filing fee, the commissioner shall waive such fee. Any such fees shall be deposited in the Insurance Fund established under section 38a-52a.

(B) The commissioner shall refund any paid filing fee to the covered person or the covered person's authorized representative, as applicable, or the health care professional if the adverse determination or the final adverse determination that is the subject of the external review request or expedited external review request is reversed or revised.

(3) The health carrier that issued the adverse determination or the final adverse determination that is the subject of the external review request or the expedited external review request shall pay the independent review organization for the cost of conducting the review.

(4) An external review decision, whether such review is a standard external review or an expedited external review, shall be binding on the health carrier or a self-insured governmental plan and the covered person, except to the extent such health carrier or covered person has other remedies available under federal or state law. A covered person or a covered person's authorized representative shall not file a subsequent request for an external review or an expedited external review that involves the same adverse determination or final adverse determination for which the covered person or the covered person's authorized representative already received an external review decision or an expedited external review decision.

(5) Each health carrier shall maintain written records of external reviews as set forth in section 38a-591h.

(6) Each independent review organization shall maintain written records as set forth in subsection (e) of section 38a-591m.

(b) (1) Except as otherwise provided under subdivision (2) of this subsection or subsection (d) of this section, a covered person or a covered person's authorized representative shall not file a request for an external review or an expedited external review until the covered person or the covered person's authorized representative has exhausted the health carrier's internal grievance process.

(2) A health carrier may waive its internal grievance process and the requirement for a covered person to exhaust such process prior to filing a request for an external review or an expedited external review.

(c) (1) At the same time a health carrier sends to a covered person or a covered person's authorized representative a written notice of an adverse determination or a final adverse determination issued by the health carrier, the health carrier shall include a written disclosure to the covered person and, if applicable, the covered person's authorized representative of the covered person's right to request an external review.

(2) The written notice shall include:

(A) The following statement or a statement in substantially similar language: “We have denied your request for benefit approval for a health care service or course of treatment. You may have the right to have our decision reviewed by health care professionals who have no association with us by submitting a request for external review to the office of the Insurance Commissioner, if our decision involved making a judgment as to the medical necessity, appropriateness, health care setting, level of care or effectiveness of the health care service or treatment you requested.”;

(B) For a notice related to an adverse determination, a statement informing the covered person that:

(i) If the covered person has a medical condition for which the time period for completion of an expedited internal review of a grievance involving an adverse determination would seriously jeopardize the life or health of the covered person or would jeopardize the covered person's ability to regain maximum function, the covered person or the covered person's authorized representative may (I) file a request for an expedited external review, or (II) file a request for an expedited external review if the adverse determination involves a denial of coverage based on a determination that the recommended or requested health care service or treatment is experimental or investigational and the covered person's treating health care professional certifies in writing that such recommended or requested health care service or treatment would be significantly less effective if not promptly initiated; and

(ii) Such request for expedited external review may be filed at the same time the covered person or the covered person's authorized representative files a request for an expedited internal review of a grievance involving an adverse determination, except that the independent review organization assigned to conduct the expedited external review shall determine whether the covered person shall be required to complete the expedited internal review of the grievance prior to conducting the expedited external review;

(C) For a notice related to a final adverse determination, a statement informing the covered person that:

(i) If the covered person has a medical condition for which the time period for completion of an external review would seriously jeopardize the life or health of the covered person or would jeopardize the covered person's ability to regain maximum function, the covered person or the covered person's authorized representative may file a request for an expedited external review; or

(ii) If the final adverse determination concerns (I) an admission, availability of care, continued stay or health care service for which the covered person received emergency services but has not been discharged from a facility, the covered person or the covered person's authorized representative may file a request for an expedited external review, or (II) a denial of coverage based on a determination that the recommended or requested health care service or treatment is experimental or investigational and the covered person's treating health care professional certifies in writing that such recommended or requested health care service or treatment would be significantly less effective if not promptly initiated, the covered person or the covered person's authorized representative may file a request for an expedited external review;

(D) (i) A copy of the description of both the standard and expedited external review procedures the health carrier is required to provide, highlighting the provisions in the external review procedures that give the covered person or the covered person's authorized representative the opportunity to submit additional information and including any forms used to process an external review or an expedited external review;

(ii) As part of any forms provided under subparagraph (D)(i) of this subdivision, an authorization form or other document approved by the commissioner that complies with the requirements of 45 CFR 164.508, as amended from time to time, by which the covered person shall authorize the health carrier and the covered person's treating health care professional to release, transfer or otherwise divulge, in accordance with sections 38a-975 to 38a-999a, inclusive, the covered person's protected health information including medical records for purposes of conducting an external review or an expedited external review;

(E) A statement that the covered person or the covered person's authorized representative may request, free of charge, copies of all documents, communications, information and evidence regarding the adverse determination or the final adverse determination that were not previously provided to the covered person or the covered person's authorized representative.

(3) Upon request pursuant to subparagraph (E) of subdivision (2) of this subsection, the health carrier shall provide such copies in accordance with subsection (b) of section 38a-591n.

(d) (1) A covered person or a covered person's authorized representative may file a request for an expedited external review of an adverse determination or a final adverse determination with the commissioner, except that an expedited external review shall not be provided for a retrospective review request of an adverse determination or a final adverse determination.

(2) Such request may be filed at the time the covered person receives:

(A) An adverse determination, if:

(i) (I) The covered person has a medical condition for which the time period for completion of an expedited internal review of the adverse determination would seriously jeopardize the life or health of the covered person or would jeopardize the covered person's ability to regain maximum function; or

(II) The denial of coverage is based on a determination that the recommended or requested health care service or treatment is experimental or investigational and the covered person's treating health care professional certifies in writing that such recommended or requested health care service or treatment would be significantly less effective if not promptly initiated; and

(ii) The covered person or the covered person's authorized representative has filed a request for an expedited internal review of the adverse determination; or

(B) A final adverse determination if:

(i) The covered person has a medical condition where the time period for completion of a standard external review would seriously jeopardize the life or health of the covered person or would jeopardize the covered person's ability to regain maximum function;

(ii) The final adverse determination concerns an admission, availability of care, continued stay or health care service for which the covered person received emergency services but has not been discharged from a facility; or

(iii) The denial of coverage is based on a determination that the recommended or requested health care service or treatment is experimental or investigational and the covered person's treating health care professional certifies in writing that such recommended or requested health care service or treatment would be significantly less effective if not promptly initiated.

(3) Such covered person or covered person's authorized representative shall not be required to file a request for an external review prior to, or at the same time as, the filing of a request for an expedited external review and shall not be precluded from filing a request for an external review, within the time periods set forth in subsection (e) of this section, if the request for an expedited external review is determined to be ineligible for such review.

(e) (1) Not later than one hundred twenty calendar days after a covered person or a covered person's authorized representative receives a notice of an adverse determination or a final adverse determination, the covered person or the covered person's authorized representative may file a request for an external review or an expedited external review with the commissioner in accordance with this section.

(2) Not later than one business day after the commissioner receives a request that is complete, the commissioner shall send a copy of such request to the health carrier that issued the adverse determination or the final adverse determination that is the subject of the request.

(3) Not later than five business days after the health carrier receives the copy of an external review request or one calendar day after the health carrier receives the copy of an expedited external review request, from the commissioner, the health carrier shall complete a preliminary review of the request to determine whether:

(A) The individual is or was a covered person under the health benefit plan at the time the health care service was requested or, in the case of an external review of a retrospective review request, was a covered person in the health benefit plan at the time the health care service was provided;

(B) The health care service that is the subject of the adverse determination or the final adverse determination is a covered service under the covered person's health benefit plan but for the health carrier's determination that the health care service is not covered because it does not meet the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness;

(C) If the health care service or treatment is experimental or investigational:

(i) Is a covered benefit under the covered person's health benefit plan but for the health carrier's determination that the service or treatment is experimental or investigational for a particular medical condition;

(ii) Is not explicitly listed as an excluded benefit under the covered person's health benefit plan;

(iii) The covered person's treating health care professional has certified that one of the following situations is applicable:

(I) Standard health care services or treatments have not been effective in improving the medical condition of the covered person;

(II) Standard health care services or treatments are not medically appropriate for the covered person; or

(III) There is no available standard health care service or treatment covered by the health carrier that is more beneficial than the recommended or requested health care service or treatment; and

(iv) The covered person's treating health care professional:

(I) Has recommended a health care service or treatment that the health care professional certifies, in writing, is likely to be more beneficial to the covered person, in the health care professional's opinion, than any available standard health care services or treatments; or

(II) Is a licensed, board certified or board eligible health care professional qualified to practice in the area of medicine appropriate to treat the covered person's condition and has certified in writing that scientifically valid studies using accepted protocols demonstrate that the health care service or treatment requested by the covered person that is the subject of the adverse determination or the final adverse determination is likely to be more beneficial to the covered person than any available standard health care services or treatments;

(D) The covered person has exhausted the health carrier's internal grievance process or the covered person or the covered person's authorized representative has filed a request for an expedited external review as provided under subsection (d) of this section; and

(E) The covered person has provided all the information and forms required to process an external review or an expedited external review, including an authorization form as set forth in subparagraph (D)(ii) of subdivision (2) of subsection (c) of this section.

(4) (A) Not later than one business day after the preliminary review of an external review request or the day the preliminary review of an expedited external review request is completed, the health carrier shall notify the commissioner, the covered person and, if applicable, the covered person's authorized representative in writing whether the request for an external review or an expedited external review is complete and eligible for such review. The commissioner may specify the form for the health carrier's notice of initial determination under this subdivision and any supporting information required to be included in the notice.

(B) If the request:

(i) Is not complete, the health carrier shall notify the commissioner and the covered person and, if applicable, the covered person's authorized representative in writing and include in the notice what information or materials are needed to perfect the request; or

(ii) Is not eligible for external review or expedited external review, the health carrier shall notify the commissioner, the covered person and, if applicable, the covered person's authorized representative in writing and include in the notice the reasons for its ineligibility.

(C) The notice of initial determination shall include a statement informing the covered person and, if applicable, the covered person's authorized representative that a health carrier's initial determination that the request for an external review or an expedited external review is ineligible for review may be appealed to the commissioner.

(D) Notwithstanding a health carrier's initial determination that a request for an external review or an expedited external review is ineligible for review, the commissioner may determine, pursuant to the terms of the covered person's health benefit plan, that such request is eligible for such review and assign an independent review organization to conduct such review. Any such review shall be conducted in accordance with this section.

(f) (1) Whenever the commissioner is notified pursuant to subparagraph (A) of subdivision (4) of subsection (e) of this section that a request is eligible for external review or expedited external review, the commissioner shall, not later than one business day after receiving such notice for an external review or one calendar day after receiving such notice for an expedited external review:

(A) Assign an independent review organization from the list of approved independent review organizations compiled and maintained by the commissioner pursuant to section 38a-591l to conduct the review and notify the health carrier of the name of the assigned independent review organization. Such assignment shall be done on a random basis among those approved independent review organizations qualified to conduct the particular review based on the nature of the health care service that is the subject of the adverse determination or the final adverse determination and other circumstances, including conflict of interest concerns as set forth in section 38a-591m; and

(B) Notify the covered person and, if applicable, the covered person's authorized representative in writing of the request's eligibility and acceptance for external review or expedited external review. For an external review, the commissioner shall include in such notice (i) a statement that the covered person or the covered person's authorized representative may submit, not later than five business days after the covered person or the covered person's authorized representative, as applicable, received such notice, additional information in writing to the assigned independent review organization that such organization shall consider when conducting the external review, and (ii) where and how such additional information is to be submitted. If additional information is submitted later than five business days after the covered person or the covered person's authorized representative, as applicable, received such notice, the independent review organization may, but shall not be required to, accept and consider such additional information.

(2) Not later than five business days for an external review or one calendar day for an expedited external review, after the health carrier receives notice of the name of the assigned independent review organization from the commissioner, the health carrier or its designee utilization review company shall provide to the assigned independent review organization the documents and any information such health carrier or utilization review company considered in making the adverse determination or the final adverse determination.

(3) The failure of the health carrier or its designee utilization review company to provide the documents and information within the time specified in subdivision (2) of this subsection shall not delay the conducting of the review.

(4) (A) If the health carrier or its designee utilization review company fails to provide the documents and information within the time period specified in subdivision (2) of this subsection, the independent review organization may terminate the review and make a decision to reverse the adverse determination or the final adverse determination.

(B) Not later than one business day after terminating the review and making the decision to reverse the adverse determination or the final adverse determination, the independent review organization shall notify the commissioner, the health carrier, the covered person and, if applicable, the covered person's authorized representative in writing of such decision.

(g) (1) The assigned independent review organization shall review all the information and documents received pursuant to subsection (f) of this section. In reaching a decision, the independent review organization shall not be bound by any decisions or conclusions reached during the health carrier's utilization review process.

(2) Not later than one business day after receiving any information submitted by the covered person or the covered person's authorized representative pursuant to subparagraph (B) of subdivision (1) of subsection (f) of this section, the independent review organization shall forward such information to the health carrier.

(3) (A) Upon the receipt of any information forwarded pursuant to subdivision (2) of this subsection, the health carrier may reconsider its adverse determination or the final adverse determination that is the subject of the review. Such reconsideration shall not delay or terminate the review.

(B) The independent review organization shall terminate the review if the health carrier decides, upon completion of its reconsideration and notice to such organization as provided in subparagraph (C) of this subdivision, to reverse its adverse determination or its final adverse determination and provide coverage or payment for the health care service or treatment that is the subject of the adverse determination or the final adverse determination.

(C) Not later than one business day after making the decision to reverse its adverse determination or its final adverse determination, the health carrier shall notify the commissioner, the assigned independent review organization, the covered person and, if applicable, the covered person's authorized representative in writing of such decision.

(h) In addition to the documents and information received pursuant to subsection (f) of this section, the independent review organization shall consider, to the extent the documents or information are available and the independent review organization considers them appropriate, the following in reaching a decision:

(1) The covered person's medical records;

(2) The attending health care professional's recommendation;

(3) Consulting reports from appropriate health care professionals and other documents submitted by the health carrier, the covered person, the covered person's authorized representative or the covered person's treating health care professional;

(4) The terms of coverage under the covered person's health benefit plan to ensure that the independent review organization's decision is not contrary to the terms of coverage under such health benefit plan;

(5) The most appropriate practice guidelines, which shall include applicable evidence-based standards and may include any other practice guidelines developed by the federal government, national or professional medical societies, medical boards or medical associations;

(6) Any applicable clinical review criteria developed and used by the health carrier or its designee utilization review company; and

(7) The opinion or opinions of the independent review organization's clinical peer or peers who conducted the review after considering subdivisions (1) to (6), inclusive, of this subsection.

(i) (1) The independent review organization shall notify the commissioner, the health carrier, the covered person and, if applicable, the covered person's authorized representative in writing of its decision to uphold, reverse or revise the adverse determination or the final adverse determination, not later than:

(A) For external reviews, forty-five calendar days after such organization receives the assignment from the commissioner to conduct such review;

(B) For external reviews involving a determination that the recommended or requested health care service or treatment is experimental or investigational, twenty calendar days after such organization receives the assignment from the commissioner to conduct such review;

(C) For expedited external reviews, except as specified under subparagraph (D) of this subdivision, as expeditiously as the covered person's medical condition requires, but not later than forty-eight hours after such organization receives the assignment from the commissioner to conduct such review or seventy-two hours after such organization receives such assignment if any portion of such forty-eight-hour period falls on a weekend;

(D) For expedited external reviews involving a health care service or course of treatment specified under subparagraph (B) or (C) of subdivision (38) of section 38a-591a, as expeditiously as the covered person's medical condition requires, but not later than twenty-four hours after such organization receives the assignment from the commissioner to conduct such review; and

(E) For expedited external reviews involving a determination that the recommended or requested health care service or treatment is experimental or investigational, as expeditiously as the covered person's medical condition requires, but not later than five calendar days after such organization receives the assignment from the commissioner to conduct such review.

(2) Such notice shall include:

(A) A general description of the reason for the request for the review;

(B) The date the independent review organization received the assignment from the commissioner to conduct the review;

(C) The date the review was conducted;

(D) The date the organization made its decision;

(E) The principal reason or reasons for its decision, including what applicable evidence-based standards, if any, were used as a basis for its decision;

(F) The rationale for the organization's decision;

(G) Reference to the evidence or documentation, including any evidence-based standards, considered by the organization in reaching its decision; and

(H) For a review involving a determination that the recommended or requested health care service or treatment is experimental or investigational:

(i) A description of the covered person's medical condition;

(ii) A description of the indicators relevant to determining whether there is sufficient evidence to demonstrate that (I) the recommended or requested health care service or treatment is likely to be more beneficial to the covered person than any available standard health care services or treatments, and (II) the adverse risks of the recommended or requested health care service or treatment would not be substantially increased over those of available standard health care services or treatments;

(iii) A description and analysis of any medical or scientific evidence considered in reaching the opinion;

(iv) A description and analysis of any evidence-based standard; and

(v) Information on whether the clinical peer's rationale for the opinion is based on the documents and information set forth in subsection (f) of this section.

(3) Upon the receipt of a notice of the independent review organization's decision to reverse or revise an adverse determination or a final adverse determination, the health carrier shall immediately approve the coverage that was the subject of the adverse determination or the final adverse determination.

(P.A. 11-58, S. 60; P.A. 12-102, S. 4; 12-145, S. 24; P.A. 13-3, S. 76; P.A. 19-117, S. 243.)

History: P.A. 11-58 effective July 1, 2011; P.A. 12-102 amended Subsec. (c) to add Subdiv. (2)(E) re statement that copies of documents, communications, information and evidence not previously provided to covered person may be requested and add Subdiv. (3) re health carrier obligation to provide copies in accordance with Sec. 38a-591n(b), and made technical changes in Subsecs. (e) and (f); P.A. 12-145 made technical changes in Subsec. (e)(3), effective June 15, 2012; P.A. 13-3 amended Subsec. (i)(1) by adding new Subpara. (D) re 24-hour notification period for expedited external reviews for substance use or mental disorder treatment, redesignating existing Subpara. (D) as Subpara. (E), and making a conforming change in Subpara. (C); P.A. 19-117 amended Subsec. (i)(1)(C) by substituting “forty-eight hours” for “seventy-two hours” and adding “or seventy-two hours after such organization receives such assignment if any portion of such forty-eight-hour period falls on a weekend”, effective January 1, 2020.