Raised H.B. No. 6586
Session Year 2021


AN ACT CONCERNING PRIOR AUTHORIZATIONS AND HEALTH CARE PROVIDER CONTRACTS.

To: (1) Require each contract between a health carrier and a health care professional or facility to (A) require the health carrier to reimburse the health care professional or facility for medically necessary covered benefits, (B) include a mechanism for the health care professional or facility to request that the health carrier reconsider a denial of coverage or refusal to reimburse, and (C) permit the health care professional or facility to collect payment for health care services that are not medically necessary; (2) provide that a health carrier shall (A) not require prior authorization for certain health care services, (B) promptly respond to prior authorization requests for post-stabilization and maintenance services, and (C) be financially responsible for post-stabilization and maintenance services if the health carrier fails to promptly respond to a prior authorization request for such services; (3) require each health carrier that enters into a participating provider contract to afford to the participating provider (A) at least ninety days' advance written notice of any proposed change to the provisions, other documents, provider manuals or policies incorporated by reference in such contract, and (B) a right to appeal any such proposed change; (4) redefine "adverse determination" and "final adverse determination", and define "hospital", "preferred provider network", "prior authorization", "prior authorization appeal" and "skilled nursing center", for the purposes of adverse determination and utilization review; (5) require certain health carriers to submit an annual prior authorization report to the Insurance Commissioner and make such report publicly available; (6) require the Insurance Commissioner to convene a prior authorization working group and require such working group to submit a report to the joint standing committees of the General Assembly having cognizance of matters relating to insurance and public health; (7) require (A) the Insurance Commissioner to establish prior authorization standards and incorporate such standards into existing health carrier audit and enforcement procedures, (B) any health carrier that fails to satisfy such standards to submit to the commissioner, and successfully implement, a corrective action plan, and (C) the commissioner to refrain from issuing or renewing a license to any health carrier that fails to satisfy such standards or, if applicable, submit and successfully implement such corrective action plan; (8) the Insurance Commissioner to develop and conduct an annual health care provider satisfaction survey and include the results of such survey in the consumer report card; (9) impose various duties on health carriers with respect to prior authorizations; (10) incorporate health carriers' duties with respect to prior authorizations into various provisions concerning adverse determination and utilization review; (11) require the Insurance Commissioner to develop and establish technical standards