Sec. 19a-755. Health Information Technology Officer.
Sec. 19a-755a. All-payer claims database program.
Sec. 19a-755b. Consumer health information Internet web site.
Secs. 19a-756 to 19a-899. Reserved
Sec. 19a-755. Health Information Technology Officer. Section 19a-755 is repealed, effective May 14, 2018.
(P.A. 16-77, S. 4; June Sp. Sess. P.A. 17-2, S. 112; P.A. 18-91, S. 80.)
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Sec. 19a-755a. All-payer claims database program. (a) As used in this section:
(1) “All-payer claims database” means a database that receives and stores data from a reporting entity relating to medical insurance claims, dental insurance claims, pharmacy claims and other insurance claims information from enrollment and eligibility files.
(2) (A) “Reporting entity” means:
(i) An insurer, as described in section 38a-1, licensed to do health insurance business in this state;
(ii) A health care center, as defined in section 38a-175;
(iii) An insurer or health care center that provides coverage under Part C or Part D of Title XVIII of the Social Security Act, as amended from time to time, to residents of this state;
(iv) A third-party administrator, as defined in section 38a-720;
(v) A pharmacy benefits manager, as defined in section 38a-479aaa;
(vi) A hospital service corporation, as defined in section 38a-199;
(vii) A nonprofit medical service corporation, as defined in section 38a-214;
(viii) A fraternal benefit society, as described in section 38a-595, that transacts health insurance business in this state;
(ix) A dental plan organization, as defined in section 38a-577;
(x) A preferred provider network, as defined in section 38a-479aa; and
(xi) Any other person that administers health care claims and payments pursuant to a contract or agreement or is required by statute to administer such claims and payments.
(B) “Reporting entity” does not include an employee welfare benefit plan, as defined in the federal Employee Retirement Income Security Act of 1974, as amended from time to time, that is also a trust established pursuant to collective bargaining subject to the federal Labor Management Relations Act.
(3) “Medicaid data” means the Medicaid provider registry, health claims data and Medicaid recipient data maintained by the Department of Social Services.
(4) “CHIP data” means the provider registry, health claims data and recipient data maintained by the Department of Social Services to administer the Children's Health Insurance Program.
(b) (1) There is established an all-payer claims database program. The Office of Health Strategy shall: (A) Oversee the planning, implementation and administration of the all-payer claims database program for the purpose of collecting, assessing and reporting health care information relating to safety, quality, cost-effectiveness, access and efficiency for all levels of health care; (B) ensure that data received is securely collected, compiled and stored in accordance with state and federal law; (C) conduct audits of data submitted by reporting entities in order to verify its accuracy; and (D) in consultation with the Health Information Technology Advisory Council established under section 17b-59f, maintain written procedures for the administration of such all-payer claims database. Any such written procedures shall include (i) reporting requirements for reporting entities, and (ii) requirements for providing notice to a reporting entity regarding any alleged failure on the part of such reporting entity to comply with such reporting requirements.
(2) The executive director of the Office of Health Strategy shall seek funding from the federal government, other public sources and other private sources to cover costs associated with the planning, implementation and administration of the all-payer claims database program.
(3) (A) Upon the adoption of reporting requirements as set forth in subdivision (1) of this subsection, a reporting entity shall report health care information for inclusion in the all-payer claims database in a form and manner prescribed by the executive director of the Office of Health Strategy. The executive director may, after notice and hearing, impose a civil penalty on any reporting entity that fails to report health care information as prescribed. Such civil penalty shall not exceed one thousand dollars per day for each day of violation and shall not be imposed as a cost for the purpose of rate determination or reimbursement by a third-party payer.
(B) The executive director of the Office of Health Strategy may provide the name of any reporting entity on which such penalty has been imposed to the Insurance Commissioner. After consultation with said executive director, the commissioner may request the Attorney General to bring an action in the superior court for the judicial district of Hartford to recover any penalty imposed pursuant to subparagraph (A) of this subdivision.
(4) The Commissioner of Social Services shall submit Medicaid and CHIP data to the executive director of the Office of Health Strategy for inclusion in the all-payer claims database only for purposes related to administration of the State Medicaid and CHIP Plans, in accordance with 42 CFR 431.301 to 42 CFR 431.306, inclusive.
(5) The executive director of the Office of Health Strategy shall: (A) Utilize data in the all-payer claims database to provide health care consumers in the state with information concerning the cost and quality of health care services for the purpose of allowing such consumers to make economically sound and medically appropriate health care decisions; and (B) make data in the all-payer claims database available to any state agency, insurer, employer, health care provider, consumer of health care services or researcher for the purpose of allowing such person or entity to review such data as it relates to health care utilization, costs or quality of health care services. If health information, as defined in 45 CFR 160.103, as amended from time to time, is permitted to be disclosed under the Health Insurance Portability and Accountability Act of 1996, P.L. 104-191, as amended from time to time, or regulations adopted thereunder, any disclosure thereof made pursuant to this subdivision shall have identifiers removed, as set forth in 45 CFR 164.514, as amended from time to time. Any disclosure made pursuant to this subdivision of information other than health information shall be made in a manner to protect the confidentiality of such other information as required by state and federal law. The executive director of the Office of Health Strategy may set a fee to be charged to each person or entity requesting access to data stored in the all-payer claims database.
(6) The executive director of the Office of Health Strategy may (A) in consultation with the All-Payer Claims Database Advisory Group set forth in section 17b-59f, enter into a contract with a person or entity to plan, implement or administer the all-payer claims database program, (B) enter into a contract or take any action that is necessary to obtain data that is the same data required to be submitted by reporting entities under Medicare Part A or Part B, (C) enter into a contract for the collection, management or analysis of data received from reporting entities, and (D) in accordance with subdivision (4) of this subsection, enter into a contract or take any action that is necessary to obtain Medicaid and CHIP data. Any such contract for the collection, management or analysis of such data shall expressly prohibit the disclosure of such data for purposes other than the purposes described in this subsection.
(c) Unless otherwise specified, nothing in this section and no action taken by the executive director of the Office of Health Strategy pursuant to this section or section 19a-755b shall be construed to preempt, supersede or affect the authority of the Insurance Commissioner to regulate the business of insurance in the state.
(June Sp. Sess. P.A. 17-2, S. 113; P.A. 18-77, S. 3; 18-91, S. 4.)
History: June Sp. Sess. P.A. 17-2 effective October 31, 2017; P.A. 18-77 amended Subsec. (a) to add Subdiv. (4) re “CHIP data” definition, and amended Subsecs. (b)(4) and (b)(6) to add references to CHIP data, effective June 1, 2018; P.A. 18-91 amended Subsec. (b) by replacing references to Health Information Technology Officer with references to executive director of the Office of Health Strategy, replacing reference to Health Information Technology Officer with reference to Office of Health Strategy, and adding Subpara. (D) re procedures for administration of all-payer claims database in Subdiv. (1), and replacing reference to Sec. 19a-755(b) with reference to Subdiv. (1) in Subdiv. (3)(A), and added Subsec. (c) re authority of the Insurance Commissioner, effective May 14, 2018.
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Sec. 19a-755b. Consumer health information Internet web site. (a) For purposes of this section and sections 19a-904a, 19a-904b and 38a-477d to 38a-477f, inclusive:
(1) “Allowed amount” means the maximum reimbursement dollar amount that an insured's health insurance policy allows for a specific procedure or service;
(2) “Consumer health information Internet web site” means an Internet web site developed and operated by the Office of Health Strategy to assist consumers in making informed decisions concerning their health care and informed choices among health care providers;
(3) “Episode of care” means all health care services related to the treatment of a condition or a service category for such treatment and, for acute conditions, includes health care services and treatment provided from the onset of the condition to its resolution or a service category for such treatment and, for chronic conditions, includes health care services and treatment provided over a given period of time or a service category for such treatment;
(4) “Executive director” means the executive director of the Office of Health Strategy;
(5) “Health care provider” means any individual, corporation, facility or institution licensed by this state to provide health care services;
(6) “Health carrier” means any insurer, health care center, hospital service corporation, medical service corporation, fraternal benefit society or other entity delivering, issuing for delivery, renewing, amending or continuing any individual or 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;
(7) “Hospital” has the same meaning as provided in section 19a-490;
(8) “Out-of-pocket costs” means costs that are not reimbursed by a health insurance policy and includes deductibles, coinsurance and copayments for covered services and other costs to the consumer associated with a procedure or service;
(9) “Outpatient surgical facility” has the same meaning as provided in section 19a-493b; and
(10) “Public or private third party” means the state, the federal government, employers, a health carrier, third-party administrator, as defined in section 38a-720, or managed care organization.
(b) (1) Within available resources, the consumer health information Internet web site shall: (A) Contain information comparing the quality, price and cost of health care services, including, to the extent practicable, (i) comparative price and cost information for the health care services and procedures reported pursuant to subsection (c) of this section categorized by payer or listed by health care provider, (ii) links to Internet web sites and consumer tools where consumers may obtain comparative cost and quality information, including The Joint Commission and Medicare hospital compare tool, (iii) definitions of common health insurance and medical terms so consumers may compare health coverage and understand the terms of their coverage, and (iv) factors consumers should consider when choosing an insurance product or provider group, including provider network, premium, cost sharing, covered services and tier information; (B) be designed to assist consumers and institutional purchasers in making informed decisions regarding their health care and informed choices among health care providers and, to the extent practicable, provide reference pricing for services paid by various health carriers to health care providers; (C) present information in language and a format that is understandable to the average consumer; and (D) be publicized to the general public. All information outlined in this section shall be posted on an Internet web site established, or to be established, by the executive director of the Office of Health Strategy in a manner and time frame as may be organizationally and financially reasonable in his or her sole discretion.
(2) Information collected, stored and published by the Office of Health Strategy pursuant to this section is subject to the federal Health Insurance Portability and Accountability Act of 1996, P.L. 104-191, as amended from time to time.
(3) The executive director of the Office of Health Strategy may consider adding quality measures to the consumer health information Internet web site.
(c) Not later than January 1, 2018, and annually thereafter, the executive director of the Office of Health Strategy shall, to the extent the information is available, make available to the public on the consumer health information Internet web site a list of: (1) The fifty most frequently occurring inpatient services or procedures in the state; (2) the fifty most frequently provided outpatient services or procedures in the state; (3) the twenty-five most frequent surgical services or procedures in the state; (4) the twenty-five most frequent imaging services or procedures in the state; and (5) the twenty-five most frequently used pharmaceutical products and medical devices in the state. Such lists may (A) be expanded to include additional admissions and procedures, (B) be based upon those services and procedures that are most commonly performed by volume or that represent the greatest percentage of related health care expenditures, or (C) be designed to include those services and procedures most likely to result in out-of-pocket costs to consumers or include bundled episodes of care.
(d) Not later than January 1, 2018, and annually thereafter, to the extent practicable, the executive director of the Office of Health Strategy shall issue a report, in a manner to be decided by the executive director, that includes the (1) billed and allowed amounts paid to health care providers in each health carrier's network for each service and procedure included pursuant to subsection (c) of this section, and (2) out-of-pocket costs for each such service and procedure.
(e) (1) On and after January 1, 2018, each hospital shall, at the time of scheduling a service or procedure for nonemergency care that is included in the report prepared by the executive director of the Office of Health Strategy pursuant to subsection (d) of this section, regardless of the location or setting where such services are delivered, notify the patient of the patient's right to make a request for cost and quality information. Upon the request of a patient for a diagnosis or procedure included in such report, the hospital shall, not later than three business days after scheduling such service or procedure, provide written notice, electronically or by mail, to the patient who is the subject of the service or procedure concerning: (A) If the patient is uninsured, the amount to be charged for the service or procedure if all charges are paid in full without a public or private third party paying any portion of the charges, including the amount of any facility fee, or, if the hospital is not able to provide a specific amount due to an inability to predict the specific treatment or diagnostic code, the estimated maximum allowed amount or charge for the service or procedure, including the amount of any facility fee; (B) the corresponding Medicare reimbursement amount or, if there is no corresponding Medicare reimbursement amount for such diagnosis or procedure, (i) the approximate amount Medicare would have paid the hospital for the services on the billing statement, or (ii) the percentage of the hospital's charges that Medicare would have paid the hospital for the services; (C) if the patient is insured, the allowed amount, the toll-free telephone number and the Internet web site address of the patient's health carrier where the patient can obtain information concerning charges and out-of-pocket costs; (D) The Joint Commission's composite accountability rating and the Medicare hospital compare star rating for the hospital, as applicable; and (E) the Internet web site addresses for The Joint Commission and the Medicare hospital compare tool where the patient may obtain information concerning the hospital.
(2) If the patient is insured and the hospital is out-of-network under the patient's health insurance policy, such written notice shall include a statement that the service or procedure will likely be deemed out-of-network and that any out-of-network applicable rates under such policy may apply.
(June Sp. Sess. P.A. 17-2, S. 114; P.A. 18-48, S. 6; 18-91, S. 5.)
History: June Sp. Sess. P.A. 17-2 effective October 31, 2017; P.A. 18-48 amended Subsec. (d) by making a technical change, effective May 29, 2018; P.A. 18-91 replaced references to Health Information Technology Officer with references to executive director of the Office of Health Strategy, amended Subsec. (a) by replacing “Health Information Technology Officer” with “Office of Health Strategy” in Subdiv. (2), adding new Subdiv. (4) re definition of “executive director”, redesignating existing Subdivs. (4) and (5) as new Subdivs. (5) and (6), and deleting former Subdiv. (6) re definition of “Health Information Technology Officer”, amended Subsec. (b) by replacing “exchange” with “Office of Health Strategy” in Subdiv. (2), replacing “adding quality measures to the Internet web site as recommended by the State Innovation Model Initiative program management office” with “adding quality measures to the consumer health information Internet web site” in Subdiv. (3), and amended Subsec. (e)(1) by making a conforming change, effective May 14, 2018.
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Secs. 19a-756 to 19a-899. Reserved for future use.
Note: Chapters 368ff to 368kk are also reserved for future use.
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