Bill Text: CT SB00160 | 2016 | General Assembly | Introduced
Bill Title: An Act Concerning Prior Authorization For The Interhospital Transfer Of Certain Newborn Infants And Their Mothers.
Spectrum: Committee Bill
Status: (Passed) 2016-06-06 - Signed by the Governor [SB00160 Detail]
Download: Connecticut-2016-SB00160-Introduced.html
General Assembly |
Raised Bill No. 160 | ||
February Session, 2016 |
LCO No. 1455 | ||
*01455_______INS* | |||
Referred to Committee on INSURANCE AND REAL ESTATE |
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Introduced by: |
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(INS) |
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AN ACT CONCERNING INSUREDS' ACCESS TO HEALTH INSURERS FOR THE PROCESSING OF CERTAIN PRIOR AUTHORIZATION REQUESTS.
Be it enacted by the Senate and House of Representatives in General Assembly convened:
Section 1. Section 38a-503c of the 2016 supplement to the general statutes is amended by adding subsection (e) as follows (Effective October 1, 2016):
(NEW) (e) Each individual health insurance carrier subject to this section that requires prior authorization for the interhospital transfer of a mother or her newborn infant shall establish and maintain a twenty-four-hour telephone number that the mother or an attending health care provider may call for a decision on such prior authorization, whether such transfer is for (1) the care or treatment of such mother or newborn infant, (2) the mother to accompany her newborn infant, or (3) the newborn infant to accompany the mother. Such telephone number shall be manned by individuals authorized to issue such decision.
Sec. 2. Section 38a-530c of the 2016 supplement to the general statutes is amended by adding subsection (e) as follows (Effective October 1, 2016):
(NEW) (e) A group health insurance carrier subject to this section that requires prior authorization for the interhospital transfer of a mother or her newborn infant shall establish and maintain a twenty-four-hour telephone number that the mother or an attending health care provider may call for a decision on such prior authorization, whether such transfer is for (1) the care or treatment of such mother or newborn infant, (2) the mother to accompany her newborn infant, or (3) the newborn infant to accompany the mother. Such telephone number shall be manned by individuals authorized to issue such decision.
Sec. 3. Subsection (d) of section 38a-591b of the 2016 supplement to the general statutes, as amended by section 10 of public act 15-146, is repealed and the following is substituted in lieu thereof (Effective October 1, 2016):
(d) Each health carrier shall:
(1) Include in the insurance policy, certificate of coverage or handbook provided to covered persons a clear and comprehensive description of:
(A) Its utilization review and benefit determination procedures;
(B) Its grievance procedures, including the grievance procedures for requesting a review of an adverse determination;
(C) A description of the external review procedures set forth in section 38a-591g, in a format prescribed by the commissioner and including a statement that discloses that:
(i) A covered person may file a request for an external review of an adverse determination or a final adverse determination with the commissioner and that such review is available when the adverse determination or the final adverse determination involves an issue of medical necessity, appropriateness, health care setting, level of care or effectiveness. Such disclosure shall include the contact information of the commissioner; and
(ii) When filing a request for an external review of an adverse determination or a final adverse determination, the covered person shall be required to authorize the release of any medical records that may be required to be reviewed for the purpose of making a decision on such request;
(D) A statement of the rights and responsibilities of covered persons with respect to each of the procedures under subparagraphs (A) to (C), inclusive, of this subdivision. Such statement shall include a disclosure that a covered person has the right to contact the commissioner's office or the Office of Healthcare Advocate at any time for assistance and shall include the contact information for said offices;
(E) A description of what constitutes a surprise bill, as defined in subsection (a) of section 38a-477aa;
(2) Inform its covered persons, at the time of initial enrollment and at least annually thereafter, of its grievance procedures. This requirement may be fulfilled by including such procedures in an enrollment agreement or update to such agreement;
(3) Inform a covered person or the covered person's health care professional, as applicable, at the time the covered person or the covered person's health care professional requests a prospective or concurrent review: (A) The network status under such covered person's health benefit plan of the health care professional who will be providing the health care service or course of treatment; (B) an estimate of the amount the health carrier will reimburse such health care professional for such service or treatment; and (C) how such amount compares to the usual, customary and reasonable charge, as determined by the Centers for Medicare and Medicaid Services, for such service or treatment;
(4) Inform a covered person and the covered person's health care professional of the health carrier's grievance procedures whenever the health carrier denies certification of a benefit requested by a covered person's health care professional;
(5) Prominently post on its Internet web site the description required under subparagraph (E) of subdivision (1) of this subsection;
(6) Include in materials intended for prospective covered persons a summary of its utilization review and benefit determination procedures;
(7) Print on its membership or identification cards a toll-free telephone number for utilization review and benefit determinations and, if applicable, the twenty-hour-hour telephone number required pursuant to subsection (e) of section 38a-503c, as amended by this act, and subsection (e) of section 38a-530c, as amended by this act, if different from the toll-free number for utilization review and benefit determinations;
(8) Maintain records of all benefit requests, claims and notices associated with utilization review and benefit determinations made in accordance with section 38a-591d for not less than six years after such requests, claims and notices were made. Each health carrier shall make such records available for examination by the commissioner and appropriate federal oversight agencies upon request; and
(9) Maintain records in accordance with section 38a-591h of all grievances received. Each health carrier shall make such records available for examination by covered persons, to the extent such records are permitted to be disclosed by law, the commissioner and appropriate federal oversight agencies upon request.
Sec. 4. Subdivision (2) of subsection (a) of section 38a-591d of the 2016 supplement to the general statutes is repealed and the following is substituted in lieu thereof (Effective October 1, 2016):
(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, or (C) that is an interhospital transfer of a mother or her newborn infant, or both, as described in subdivision (1), (2), or (3) of subsection (e) of section 38a-503c, as amended by this act, or subdivision (1), (2) or (3) of subsection (e) of section 38a-530c, as amended by this act, shall be deemed an urgent care request.
This act shall take effect as follows and shall amend the following sections: | ||
Section 1 |
October 1, 2016 |
38a-503c |
Sec. 2 |
October 1, 2016 |
38a-530c |
Sec. 3 |
October 1, 2016 |
38a-591b(d) |
Sec. 4 |
October 1, 2016 |
38a-591d(a)(2) |
Statement of Purpose:
To require health insurers that require prior authorization for the interhospital transfer of a newborn infant or such newborn infant's mother to establish and maintain a manned, twenty-four-hour telephone number for the issuance of decisions regarding such prior authorization requests.
[Proposed deletions are enclosed in brackets. Proposed additions are indicated by underline, except that when the entire text of a bill or resolution or a section of a bill or resolution is new, it is not underlined.]