Source: https://www.cga.ct.gov/2018/FC/2018SB-00384-R000338-FC.htm
Timestamp: 2019-01-23 03:32:10
Document Index: 146552857

Matched Legal Cases: ['§ 38', '§38', '§ 8', '§ 1', '§ 1', '§ 4', '§ 7', '§ 6', '§ 10']

Section 1. (NEW) (Effective January 1, 2019) For the purposes of this section and sections 2 to 5, inclusive, of this act:
(2) "Covered benefits" means any health care services to which an enrollee or insured is entitled under the terms of any individual or group health insurance policy.
(3) "Department" means the Insurance Department.
(4) "Generally accepted standards of medical practice" has the same meaning as provided in section 38a-482a of the general statutes.
(5) "Group health insurance policy" means any group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469 of the general statutes.
(6) "Health care provider" or "provider" means a person licensed to provide health care services under chapters 370 to 373, inclusive, 375 to 383c, inclusive, 384a to 384c, inclusive, and 400j of the general statutes.
(7) "Health care services" or "services" means services for the diagnosis, prevention, treatment, cure or relief of a mental or nervous condition, physical health condition or substance use disorder.
(8) "Health carrier" or "carrier" means an insurer, fraternal benefit society, health care center, hospital service corporation, managed care organization, medical service corporation or other entity that delivers, issues for delivery, renews, amends or continues in this state any individual or group health insurance policy.
(9) "Individual health insurance policy" means any individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469 of the general statutes.
(10) "Medically necessary" means health care services that a provider, actively practicing in this state in the relevant practice area and exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are (A) in accordance with generally accepted standards of medical practice, (B) clinically appropriate, in terms of type, frequency, extent, site and duration and considered effective for the patient's illness, injury or disease, and (C) not primarily for the convenience of the patient or provider and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness, injury or disease.
(11) "Mental health benefits" means covered benefits for any health care services rendered to prevent, evaluate, diagnose or treat one or more mental or nervous conditions.
(12) "Mental Health Parity and Addiction Equity Act" means 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.
(13) "Mental or nervous condition" has the same meaning as provided in section 38a-488a of the general statutes, as amended by this act.
(14) "Nonquantitative treatment limitation" means any evidentiary standard, process, strategy or other nonnumerical factor that has the effect of denying or limiting a covered benefit.
(15) "Physical health benefits" means covered benefits for any health care services rendered to prevent, evaluate, diagnose or treat one or more physical health conditions.
(16) "Physical health condition" means any illness or dysfunction of, or injury to, the human body. "Physical health condition" does not include any (A) mental or nervous condition, or (B) substance use disorder.
(17) "Substance abuse benefits" means covered benefits for any health care services rendered to prevent, evaluate, diagnose or treat one or more substance use disorders.
(18) "Substance use disorder" means any moderate or severe alcohol or substance use disorder, as defined in the most recent edition of the American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Disorders."
Sec. 2. (NEW) (Effective January 1, 2019) Each health carrier shall comply with the Mental Health Parity and Addiction Equity Act in addition to the requirements of state laws and regulations. If there is a conflict, the Mental Health Parity and Addiction Equity Act shall govern.
Sec. 3. (NEW) (Effective January 1, 2019) (a) On or before March first of each year, each health carrier shall submit to the commissioner a report covering the preceding calendar year. The report shall be on a form prescribed by the commissioner and shall include:
(1) (A) With respect to claims for mental health benefits the carrier received, and for each category of services set forth in subparagraph (D) of this subdivision, (i) the ratio of the total number of claims for which the carrier required prior authorization to the total number of claims the carrier received, (ii) the ratio of the total number of claims the carrier denied to the total number of claims the carrier received, (iii) the reason the carrier denied any claim, and (iv) the amount of the reimbursement that the carrier paid to the provider who provided such benefits;
(B) With respect to claims for physical health benefits the carrier received, and for each category of services set forth in subparagraph (D) of this subdivision, (i) the ratio of the total number of claims for which the carrier required prior authorization to the total number of claims the carrier received, (ii) the ratio of the total number of claims the carrier denied to the total number of claims the carrier received, (iii) the reason the carrier denied any claim, and (iv) the amount of the reimbursement that the carrier paid to the provider who provided such benefits;
(C) With respect to claims for substance abuse benefits the carrier received, and for each category of services set forth in subparagraph (D) of this subdivision, (i) the ratio of the total number of claims for which the carrier required prior authorization to the total number of claims the carrier received, (ii) the ratio of the total number of claims the carrier denied to the total number of claims the carrier received, (iii) the reason the carrier denied any claim, and (iv) the amount of the reimbursement that the carrier paid to the provider who provided such benefits; and
(D) Each carrier shall disclose information under subparagraphs (A) to (C), inclusive, of this subdivision for (i) in-network services provided on an inpatient basis, (ii) in-network services provided on an outpatient basis, (iii) out-of-network services provided on an inpatient basis, (iv) out-of-network services provided on an outpatient basis, (v) emergency medical services, and (vi) pharmaceutical services and products;
(2) With respect to any criteria the carrier used to determine whether a particular service was medically necessary and therefore covered as a mental health benefit, physical health benefit or substance abuse benefit, a statement (A) describing the criteria, (B) describing all processes and methods used to develop the criteria, and (C) with respect to any criteria developed by the carrier, a statement by the carrier certifying that an independent provider, actively practicing in this state and in the relevant specialty area, determined that the criteria were, at the time the carrier adopted the criteria, consistent with generally accepted standards of medical practice;
(3) With respect to each nonquantitative treatment limitation the carrier used during the relevant calendar year, a statement (A) describing the nonquantitative treatment limitation, (B) disclosing whether the carrier used the nonquantitative treatment limitation with respect to claims for mental health benefits, physical health benefits, substance abuse benefits or any combination thereof, (C) describing all processes and methods used to develop the nonquantitative treatment limitation, (D) describing all factors the carrier considered and used in determining whether it would apply the nonquantitative treatment limitation to a particular covered benefit, (E) describing all factors the carrier considered but did not use in determining whether it would apply the nonquantitative treatment limitation to a particular covered benefit, (F) by the carrier certifying that it did not apply the nonquantitative treatment limitation more stringently to claims for mental health benefits and substance abuse benefits than physical health benefits, and (G) describing the processes and methods the carrier used to ensure that it did not apply the nonquantitative treatment limitation more stringently to claims for mental health benefits or substance abuse benefits than claims for physical health benefits;
(4) A statement from the carrier certifying, after review of its internal standards, practices and procedures, that it is in compliance with (A) sections 38a-488a and 38a-514 of the general statutes, as amended by this act, as applicable, (B) the Mental Health Parity and Addiction Equity Act, and (C) the Patient Protection and Affordable Care Act, P.L. 111-148, as amended from time to time, and regulations adopted thereunder; and
(b) The commissioner may require that any carrier, in making a report under subsection (a) of this section, disclose information deemed by the carrier to be of a proprietary or competitive nature, provided the commissioner shall maintain the information as confidential and shall not disclose the information to any person except to the extent necessary to carry out the purposes of sections 1 to 5, inclusive, of this act. For the purposes of sections 1 to 5, inclusive, of this act, information is of a proprietary or competitive nature if revealing the information would cause the carrier's competitors to obtain valuable business information.
(c) The information required under subsection (a) of this section shall be posted on the department's Internet web site, except that no information that is of a proprietary or competitive nature within the meaning of subsection (b) of this section shall be posted on the department's Internet web site.
(d) The commissioner may accept any part of the filing required under subsection (a) of this section in electronic form.
Sec. 4. (NEW) (Effective January 1, 2019) (a) Not later than June 1, 2019, and annually thereafter, the commissioner shall submit a report, in accordance with section 11-4a of the general statutes, to the joint standing committee of the General Assembly having cognizance of matters relating to insurance. The report shall include the following information and statements for the preceding calendar year:
(1) A statement describing all processes and methods the department used to ensure that each health carrier complied with the Mental Health Parity and Addiction Equity Act and the results of such processes and methods;
(2) A statement describing all processes and methods the department used to ensure that each carrier complied with sections 38a-488a and 38a-514 of the general statutes, as amended by this act, and the results of such processes and methods;
(3) A statement describing any efforts the department made to educate carriers concerning compliance with section 2 of this act and any regulations adopted under section 5 of this act;
(4) A statement describing any efforts the department made to educate the public concerning the requirement that carriers comply with section 2 of this act and any regulations adopted under section 5 of this act; and
(5) A statement describing any actions the department has taken to enforce section 2 of this act or any regulations adopted under section 5 of this act.
(b) The report required under subsection (a) of this section shall be in plain language.
(c) The report required under subsection (a) of this section shall be posted on the department's Internet web site.
(d) The joint standing committee of the General Assembly having cognizance of matters relating to insurance may require the commissioner to attend an informational hearing following its receipt of a report submitted under subsection (a) of this section. The commissioner shall attend and be available for questions from the members of the committee at the hearing.
Sec. 5. (NEW) (Effective January 1, 2019) The commissioner shall adopt regulations, in accordance with chapter 54 of the general statutes, to implement the provisions of sections 1 to 4, inclusive, of this act.
Sec. 6. Section 38a-478c of the general statutes is repealed and the following is substituted in lieu thereof (Effective January 1, 2019):
(a) On or before May first of each year, each managed care organization shall submit to the commissioner:
(1) A report on its quality assurance plan that includes, but is not limited to, information on complaints related to providers and quality of care, on decisions related to patient requests for coverage and on prior authorization statistics. Statistical information shall be submitted in a manner permitting comparison across plans and shall include, but not be limited to: (A) The ratio of the number of complaints received to the number of enrollees; (B) a summary of the complaints received related to providers and delivery of care or services and the action taken on the complaint; (C) the ratio of the number of prior authorizations denied to the number of prior authorizations requested; (D) the number of utilization review determinations made by or on behalf of a managed care organization not to certify an admission, service, procedure or extension of stay, and the denials upheld and reversed on appeal within the managed care organization's utilization review procedure; (E) the percentage of those employers or groups that renew their contracts within the previous twelve months; and (F) notwithstanding the provisions of this subsection, on or before July first of each year, all data required by the National Committee for Quality Assurance for its Health Plan Employer Data and Information Set. If an organization does not provide information for the National Committee for Quality Assurance for its Health Plan Employer Data and Information Set, then it shall provide such other equivalent data as the commissioner may require by regulations adopted in accordance with the provisions of chapter 54. The commissioner shall find that the requirements of this subdivision have been met if the managed care plan has received a one-year or higher level of accreditation by the National Committee for Quality Assurance and has submitted the Health Plan Employee Data Information Set data required by subparagraph (F) of this subdivision;
(2) A model contract that contains the provisions currently in force in contracts between the managed care organization and preferred provider networks in this state, and the managed care organization and participating providers in this state and, upon the commissioner's request, a copy of any individual contracts between such parties, provided the contract may withhold or redact proprietary fee schedule information;
(3) A written statement of the types of financial arrangements or contractual provisions that the managed care organization has with hospitals, utilization review companies, physicians, preferred provider networks and any other health care providers including, but not limited to, compensation based on a fee-for-service arrangement, a risk-sharing arrangement or a capitated risk arrangement;
(4) Such information as the commissioner deems necessary to complete the consumer report card required pursuant to section 38a-478l, as amended by this act. Such information may include, but need not be limited to: (A) The organization's characteristics, including its model, its profit or nonprofit status, its address and telephone number, the length of time it has been licensed in this and any other state, its number of enrollees and whether it has received any national or regional accreditation; (B) a summary of the information required by subdivision (3) of this subsection, including any change in a plan's rates over the prior three years, its state medical loss ratio and its federal medical loss ratio, as both terms are defined in section 38a-478l, as amended by this act, how it compensates health care providers and its premium level; (C) a description of services, the number of primary care physicians and specialists, the number and nature of participating preferred provider networks and the distribution and number of hospitals, by county; (D) utilization review information, including the name or source of any established medical protocols and the utilization review standards; (E) medical management information, including the provider-to-patient ratio by primary care provider and specialty care provider, the percentage of primary and specialty care providers who are board certified, and how the medical protocols incorporate input as required in section 38a-478e; (F) the quality assurance information required to be submitted under the provisions of subdivision (1) of subsection (a) of this section; (G) the status of the organization's compliance with the reporting requirements of this section; (H) whether the organization markets to individuals and Medicare recipients; (I) the number of hospital days per thousand enrollees; and (J) the average length of hospital stays for specific procedures, as may be requested by the commissioner;
(5) A summary of the procedures used by managed care organizations to credential providers; [and]
(6) A report on claims denial data for lives covered in the state for the prior calendar year, in a format prescribed by the commissioner, that includes: (A) The total number of claims received; (B) the total number of claims denied; (C) the total number of denials that were appealed; (D) the total number of denials that were reversed upon appeal; (E) (i) the reasons for the denials, including, but not limited to, "not a covered benefit", "not medically necessary" and "not an eligible enrollee", (ii) the total number of times each reason was used, and (iii) the percentage of the total number of denials each reason was used; and (F) other information the commissioner deems necessary; [.]
(7) A report, by county, on: (A) The estimated prevalence of substance use disorders, as described in section 17a-458, among covered children, young adults and adults; (B) the number and percentage of covered children, young adults and adults who received covered treatment of a substance use disorder by level of care provided; (C) the median length of a covered treatment provided to covered children, young adults and adults for a substance use disorder by level of care provided; (D) the per member, per month claim expenses for covered children, young adults and adults who received covered treatment of substance use disorders; and (E) the number of in-network health care providers who provide treatment of substance use disorders, by level of care, and the percentage of such providers who are accepting new clients under such managed care organization's plan or plans. For the purposes of this subdivision, "children" means individuals less than sixteen years of age, "young adults" means individuals sixteen years of age or older but less than twenty-six years of age and "adults" means individuals twenty-six years of age or older;
(8) A state-wide report on the number, by licensure type, of health care providers who provide treatment of substance use disorders, co-occurring disorders and mental disorders, who, in the calendar year immediately preceding for the initial report and since the last report submitted to the commissioner for subsequent reports, (A) have applied for in-network status and the percentage of those who were accepted for such status, and (B) no longer participate in the network;
(9) A state-wide report on the number, by level of care provided, of health care facilities that provide treatment of substance use disorders, co-occurring disorders and mental disorders that, in the calendar year immediately preceding for the initial report and since the last report submitted to the commissioner for subsequent reports, (A) have applied for in-network status and the percentage of those that were accepted for such status, and (B) no longer participate in the network;
(10) A report identifying and explaining factors that may be negatively impacting covered individuals' access to treatment of substance use disorders, co-occurring disorders and mental disorders which may include, but need not be limited to, screening procedures, the state-wide supply of certain categories of health care providers, health care provider capacity limitations and provider reimbursement rates; and
(11) Plans and ongoing or completed activities to address the factors identified in subdivision (10) of this subsection.
(b) The information required pursuant to subdivisions (1) to (6), inclusive, of subsection (a) of this section shall be consistent with the data required by the National Committee for Quality Assurance (NCQA) for its Health Plan Employer Data and Information Set (HEDIS).
(e) The information required under subdivision (6) of subsection (a) of this section shall be posted on the Insurance Department's Internet web site.
Sec. 7. Section 38a-478l of the general statutes is repealed and the following is substituted in lieu thereof (Effective January 1, 2019):
(a) Not later than October fifteenth of each year, the Insurance Commissioner, after consultation with the Commissioner of Public Health, shall develop and distribute a consumer report card on all managed care organizations. The commissioner shall develop the consumer report card in a manner permitting consumer comparison across organizations.
(b) (1) The consumer report card shall be known as the "Consumer Report Card on Health Insurance Carriers in Connecticut" and shall include (A) all health care centers licensed pursuant to chapter 698a, (B) the fifteen largest licensed health insurers that use provider networks and that are not included in subparagraph (A) of this subdivision, (C) the state medical loss ratio of each such health care center or licensed health insurer, (D) the federal medical loss ratio of each such health care center or licensed health insurer, (E) the information required under [subdivision] subdivisions (6) and (7) of subsection (a) of section 38a-478c, as amended by this act, and (F) the information [concerning mental health services, as specified in] required under subsection (c) of this section for each such licensed health insurer. The insurers selected pursuant to subparagraph (B) of this subdivision shall be selected on the basis of Connecticut direct written health premiums from such network plans.
(2) For the purposes of this section and sections 38a-477c, 38a-478c, as amended by this act, and 38a-478g:
(A) "State medical loss ratio" means the ratio of incurred claims to earned premiums for the prior calendar year for managed care plans issued in the state. Claims shall be limited to medical expenses for services and supplies provided to enrollees and shall not include expenses for stop loss coverage, reinsurance, enrollee educational programs or other cost containment programs or features;
(B) "Federal medical loss ratio" has the same meaning as provided in, and shall be calculated in accordance with, the Patient Protection and Affordable Care Act, P.L. 111-148, as amended from time to time, and regulations adopted thereunder.
(c) [With respect to mental health services, the consumer report card shall include information or measures with respect to the percentage of enrollees receiving mental health services, utilization of mental health and chemical dependence services, inpatient and outpatient admissions, discharge rates and average lengths of stay.] (1) On or before May first of each year, each health insurer that provides coverage as set forth in section 38a-488a, as amended by this act, or 38a-514, as amended by this act, shall submit to the commissioner:
(A) Data for benefit requests, utilization review of benefit requests, adverse determinations and final adverse determinations for the treatment of acute and routine substance use disorders, co-occurring disorders and mental disorders: (i) Grouped according to levels of care, including, but not limited to, inpatient, outpatient, residential care and partial hospitalization; (ii) grouped by category for substance use disorders, co-occurring disorders and mental disorders; and (iii) grouped by children, young adults and adults. For the purposes of this subparagraph, "children" means individuals less than sixteen years of age, "young adults" means individuals sixteen years of age or older but less than twenty-six years of age and "adults" means individuals twenty-six years of age or older; and
(B) Data for external appeals for the treatment of substance use disorders, co-occurring disorders and mental disorders, grouped in accordance with subparagraphs (A)(i) to (A)(iii), inclusive, of this subdivision.
(2) Such data shall be collected in a manner consistent with the National Committee for Quality Assurance Health Plan Employer Data and Information Set measures.
(e) The commissioner shall analyze annually the data submitted under subparagraphs (E) and (F) of subdivision (1) of subsection (b) of this section for the accuracy of, trends in and statistically significant differences in such data among the health care centers and licensed health insurers included in the consumer report card. The commissioner may investigate any such differences to determine whether further action by the commissioner is warranted.
Sec. 8. Section 38a-488a of the 2018 supplement to the general statutes is repealed and the following is substituted in lieu thereof (Effective January 1, 2019):
(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.
(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; and
(21) Screening for mental or nervous conditions during any annual physical examination conducted by a licensed health care provider.
Sec. 9. Section 38a-514 of the 2018 supplement to the general statutes is repealed and the following is substituted in lieu thereof (Effective January 1, 2019):
Sec. 10. Section 19a-754a of the 2018 supplement to the general statutes is repealed and the following is substituted in lieu thereof (Effective January 1, 2019):
(a) There is established an Office of Health Strategy, which shall be within the Department of Public Health for administrative purposes only. The department head of said office shall be the executive director of the Office of Health Strategy, who shall be appointed by the Governor in accordance with the provisions of sections 4-5 to 4-8, inclusive, with the powers and duties therein prescribed.
(b) On or before July 1, 2018, the Office of Health Strategy shall be responsible for the following:
(c) Not later than June 30, 2019, and quarterly thereafter until and including March 31, 2021, the Office of Health Strategy shall report to the joint standing committees of the General Assembly having cognizance of matters relating to public health and insurance on the activities the office has undertaken and the progress the office has made to have the all-payer claims database, as defined in section 19a-755a, provide the data described in subdivisions (7) to (11), inclusive, of subsection (a) of section 38a-478c, as amended by this act, and subdivision (1) of subsection (c) of section 38a-478l, as amended by this act.
(1) The Connecticut Health Insurance Exchange, established pursuant to section 38a-1081, relating to the administration of the all-payer claims database pursuant to section 19a-755a; and
38a-478c
38a-478l
In Section 1(10), "or "medical necessity"" was deleted for statutory consistency and Section 6(a)(10) was rewritten for clarity.
GF&TF - Potential Cost
The bill may result in a cost to the state employee and retiree health plan as well as fully insured municipal plans to the extent that the bill increases utilization of mental health screening services pursuant to section 9(b)(21) of the bill. The potential cost will accrue to the state and municipalities to the extent screenings are conducted during a physical exam or as a result of a referral to another licensed practitioner. The plan currently limits coverage for mental health services to those “…provided by Providers who are certified by the appropriate state agency to provide such services and whose programs for such services have been approved by the Carrier.”1 It is uncertain if screening for a mental or nervous condition as defined by CGS § 38a-488a would be covered at an annual physical exam. Under current law, three screenings specified (e.g. trauma screening, substance use screening, and depression screening) require coverage conducted by a licensed behavioral health professional (CGS §38a-488). The bill does not define “screening”. The fiscal impact to fully-insured municipalities will be reflected in premiums for plan years effective on or after January 1, 2019. Due to federal law, self-insured plans are exempt from state health mandates.2
The bill's various reporting requirements are not anticipated to result in a fiscal impact to the state or municipal health plans.
The bill is not anticipated to result in a fiscal impact to the Insurance Department from expanded data collection, analysis and reporting requirements. The provisions are similar to existing Department activities and fall within Department's expertise.
The annualized ongoing fiscal impact identified above would continue into the future subject to the utilization of services and for fully-insured municipalities, will be reflected in future premiums.
sSB 384
This bill requires certain health insurance policies to cover, at an annual physical, screenings for mental or nervous conditions. It also:
1. expands reporting requirements for the insurance commissioner, managed care organizations, health carriers, health insurers, and the all-payers claims database and
2. changes the data that must be included in the Consumer Report Card on Health Insurance Carriers in Connecticut and, in doing so, changes the data the insurance commissioner may investigate for discrepancies.
Additionally, it specifies that (1) health carriers must comply with the federal Mental Health Parity and Addiction Equity Act (MHPAEA) (P.L. 110-343) and (2) the federal act prevails in any conflict with state law or regulation and allows the commissioner to adopt implementing regulations.
§§ 8 & 9 — SCREENING COVERAGE
§§ 1, 3 & 5 — HEALTH CARRIER REPORT TO THE COMMISSIONER
Under the bill, health carriers must submit to the insurance commissioner, annually by March 1, a report covering the preceding calendar year that includes information the bill specifies in a form she prescribes. The commissioner may require that a carrier, in making the report, disclose proprietary or competitive information. She must maintain this information's confidentiality and is prohibited from disclosing it to any person unless necessary to carry out the bill's provisions. The bill allows the commissioner to accept a report submitted electronically.
Under the bill, a medically necessary health care service is one that a provider actively practicing in Connecticut, in the relevant practice area, would provide to prevent, evaluate, diagnose, or treat an illness, injury, or disease or its symptoms. Medically necessary services must also be (1) in accordance with generally accepted medical practice standards; (2) clinically appropriate in type, frequency, extent, site, and duration for the patient's illness, injury, or disease; (3) not primarily for the patient's or provider's convenience; and (4) not more costly than other therapeutically or diagnostically equivalent services that are at least as likely to produce equivalent therapeutic or diagnostic results.
Nonquantitative Treatment Limitations. The report must also describe each nonquantitative treatment limitation used during the preceding calendar year, including:
1. whether the carrier used such a limitation with respect to any mental health, physical health, or substance abuse benefits, or any combination thereof;
2. all processes and methods used to develop the limitation;
3. all factors the carrier considered and did or did not use in deciding whether to apply the limitation to a particular covered benefit; and
4. a certification that it did not apply the limitations more stringently to claims for mental health and substance abuse benefits than it did to claims for physical health benefits.
§§ 1, 4, 5 & 7 — INSURANCE COMMISSIONER REPORTING REQUIREMENTS
Report to the Insurance and Real Estate Committee (§ 4)
The bill requires the commissioner to begin annually reporting to the Insurance and Real Estate Committee by June 1, 2019. The report must describe, for the preceding year, the department's:
1. processes and methods used to ensure compliance with MHPAEA and the results;
2. processes and methods used to ensure compliance with state mental health parity laws and the results;
3. efforts to educate health carriers regarding their responsibility to comply with MHPAEA and any regulations adopted under the bill, including regulations adopted to implement the reporting requirement described above;
4. public education efforts regarding carriers' compliance with MHPAEA and any adopted regulations; and
5. actions taken to enforce the health carriers' compliance with MHPAEA and any adopted regulations.
The bill requires the (1) report to be in plain language and posted on the departments website and (2) commissioner to adopt implementing regulations.
Under the bill, the Insurance and Real Estate Committee may require the commissioner to attend an informational hearing and be available to answer questions regarding the report.
Consumer Report Card (§ 7)
The bill makes changes to the consumer report card, which is an annual report issued by the commissioner that contains certain comparative information, including each insurer's state and federal medical loss ratio (i.e., the ratio of incurred claims to earned premiums).
The bill removes requirements that the report card provide certain data related to mental health services, including (1) the percent of enrollees receiving mental health services, (2) the utilization of mental health and chemical dependence services, (3) inpatient and outpatient admissions, (4) discharge rates, and (5) average stay lengths. The bill instead requires the report card to contain the prevalence, by county, of substance use disorders in children, young adults, and adults covered by managed care organizations, as reported by the organizations (see below).
By law, the insurance commissioner must analyze certain information she receives for the consumer report card to determine the accuracy of, trends in, and statistically significant difference among such information for the health care centers and insurers in Connecticut. She may also investigate such differences to determine if further action is warranted. By adding mental health services data to the report card, the bill also requires the commissioner to analyze that data and permits her to investigate any discrepancies.
The bill also requires, by May 1 annually, each health insurer providing coverage for mental or nervous conditions to submit to the commissioner data for:
By law, the commissioner must analyze such data for accuracy and statistically significant differences between health care centers and may investigate any discrepancies she finds.
§ 6 — MANAGED CARE ORGANIZATIONS
The bill requires managed care organizations to report certain substance use disorder treatment information to the commissioner annually by May 1.
Under the bill, managed care organizations must report on the prevalence of substance use disorders in covered children (i.e., under 16 years old), young adults (i.e., age 16 through 25), and adults (i.e., age 26 and older), by county. The report must include the:
1. number and percent of covered children, young adults, and adults who received covered substance use disorder treatment, by level of care provided;
2. median length of a covered treatment for such individuals, by level of care provided;
3. per member per month claim expenses for such individuals who received covered substance use disorder treatments; and
4. number of in-network health care providers providing substance use disorder treatment, by level of care, and the percent accepting new in-network clients.
Presumably, the report contains such information for the preceding year.
Substance Use Disorder Provider and Health Care Facility Reports
Under the bill, managed care organizations must also report on the number of (1) health care providers treating substance use disorders, co-occurring disorders, and mental disorders by license type, and (2) health care facilities treating such disorders, by level of care provided.
The reports must include only those providers or facilities who, since the last report, (1) applied for in-network status, and the percentage accepted and (2) no longer participate in the network. (The bill does not appear to require the number of current providers or facilities; only the number that entered or left the network.)
Substance Use Disorder Treatment Obstacles Report
Managed care organizations must also identify and explain factors that may be negatively impacting a covered individual's access to substance use, co-occurring, or mental disorder treatment, including (1) screening procedures, (2) statewide supply of certain providers and their capacity, and (3) provider reimbursement rates. The report must include plans and ongoing or completed activities to address these factors.
Office of Health Strategy (§ 10)
The bill requires the Office of Health Strategy to report, beginning June 30, 2019 and quarterly thereafter, to the Public Health and Insurance and Real Estate committees on the office's activities and progress related to requiring the all-payer claims database to provide the new data the bill requires managed care organizations to annually report to the commissioner.
1 Source: State of Connecticut Health Benefit Plan – Plan Document.
2 The state employee and non-Medicare retiree health plan are self-insured and therefore are exempt from state health mandates. However, the state has traditionally adopted all state mandated benefits. Self-insured municipalities are likewise exempt from state health mandates.