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. Preexisting condition coverage. Routine follow-up care to determine whether a breast cancer has reoccurred in a person who has been previously determined to be breast cancer free shall not be considered as medical advice, diagnosis, care or treatment for purposes of this section unless evidence of breast cancer is found during or as a result of such follow-up.
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. If the same insurer or health care center issues a third or subsequent such short-term health insurance policy to the same individual, such insurer or health care center shall reduce the preexisting conditions exclusion period in the third or subsequent policy by the cumulative time covered under the prior policies.
Nothing in this section shall be construed to require such short-term health insurance policy to be issued on a guaranteed issue or guaranteed renewable basis. History: June 18 Sp. Notwithstanding any provision of the general statutes or the regulations of Connecticut state agencies, no mental health care benefit provided under state law, or with state funds or to state employees may, through the use of a drug formulary, list of covered drugs or any other means: 1 Limit the availability of psychotropic drugs that are the most effective therapeutically indicated pharmaceutical treatment with the least probability of adverse side effects; or 2 require utilization of psychotropic drugs that are not the most effective therapeutically indicated pharmaceutical treatment with the least probability of adverse side effects.
Nothing in this section shall be construed to limit the authority of a physician to prescribe a drug that is not the most recent pharmaceutical treatment.
Nothing in this section shall be construed to prohibit differential copays among pharmaceutical treatments or to prohibit utilization review. Item Description. The Insurance Commissioner shall provide written or electronic notification to each insurance company, fraternal benefit society, hospital service corporation, medical service corporation, health care center or any other entity that delivers or issues for delivery, in this state, any individual or group health insurance plan 1 of any benefits required to be provided in such plan pursuant to this chapter, or of any modification to such benefits on or after October 1, , at least thirty days prior to the date such benefits or modification becomes effective, and 2 instructing such company, society, corporation, center or other entity to submit to the Insurance Commissioner, prior to the date such benefits or modification becomes effective or upon the renewal date of the plan, any necessary policy forms, in accordance with the provisions of section 38a or 38a, as applicable, that reflect such benefits or modification.
No insurer or health care center may rescind, cancel or limit any such policy, contract, evidence of coverage or certificate more than two years after the effective date of the policy, contract, evidence of coverage or certificate. Such insurer or health care center shall provide a copy of the application for such approval to the insured or the insured's representative.
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Not later than seven business days after receipt of the application for such approval, the insured or the insured's representative shall have an opportunity to review such application and respond and submit relevant information to the commissioner with respect to such application. Not later than fifteen business days after the submission of information by the insured or the insured's representative, the commissioner shall issue a written decision on such application.
The commissioner shall only approve:. Such decision shall be mailed to the insured, the insured's representative, if any, and the insurer or health care center; and. Such citation shall be signed by the same authority, and such appeal shall be returnable at the same time and served and returned in the same manner, as is required in case of a summons in a civil action. Said court may grant such relief as may be equitable. An insurer or health care center shall include a written notice with each application for individual or group health insurance coverage that discloses such insurer's or health care center's state medical loss ratio and federal medical loss ratio, as both terms are defined in section 38a l , as reported in the last Consumer Report Card on Health Insurance Carriers in Connecticut, to an applicant at the time of application for coverage.
E re coverage of noncovered outpatient prescription drugs, effective January 1, If in any year, a health carrier exceeds forty thousand covered lives in the state, the provisions of this section shall begin to apply on January first in the following year. Information described in subdivisions 1 and 2 of this subsection may be used to assist consumers and institutional purchasers in making informed decisions regarding their health care and informed choices among health care providers and allow comparisons between prices paid by various health carriers to health care providers.
The invalidity or unenforceability of any contract provision under this subsection shall not affect any other provision of the contract. A A hold harmless provision that specifies protections for covered persons. This agreement does not prohibit the provider from collecting coinsurance, deductibles or copayments, as specifically provided in the evidence of coverage, or fees for uncovered services delivered on a fee-for-service basis to covered persons. Nor does this agreement prohibit a provider except for a health care provider who is employed full-time on the staff of a health carrier and has agreed to provide services exclusively to that health carrier's covered persons and no others and a covered person from agreeing to continue services solely at the expense of the covered person, as long as the provider has clearly informed the covered person that the health carrier does not cover or continue to cover a specific service or services.
Except as provided herein, this agreement does not prohibit the provider from pursuing any available legal remedy. C i A provision that requires the participating provider to make health records available to appropriate state and federal authorities involved in assessing the quality of care provided to, or investigating grievances or complaints of, covered persons, and ii a statement that such participating provider shall comply with applicable state and federal laws related to the confidentiality of medical and health records and a covered person's right to view, obtain copies of or amend such covered person's medical and health records; and.
D Definitions of what is considered timely notice and a material change for the purposes of subdivision 2 of subsection c of this section.
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B Each intermediary and participating providers with whom such intermediary contracts shall comply with the applicable requirements of this subsection. To the extent a health carrier assigns or delegates to an intermediary other responsibilities, such health carrier shall retain full responsibility for such intermediary's compliance with the requirements of this section. Such health carrier shall have the right, upon twenty days' prior written notice, to make copies of any intermediary subcontracts to facilitate regulatory review. B Each health carrier shall monitor the timeliness and appropriateness of payments made by its intermediary to participating providers and of health care services received by covered persons.
If a health carrier requires such assignment, such health carrier shall remain obligated to pay the participating provider for providing covered benefits under the same terms and conditions as the intermediary prior to the insolvency.
Health Insurance: Premiums and Increases
The health carrier shall ensure that consumers are able to view all of the current participating providers for a network plan through a clearly identifiable link or tab on such health carrier's Internet web site, without being required to create or access an account or enter a policy or contract number. A For health care providers, i the health care provider's name, gender, participating office location or locations, specialty, if applicable, medical group affiliations, if any, facility affiliations, if applicable, participating facility affiliations, if applicable, ii any languages other than English spoken by such health care provider, iii whether such health care provider is accepting new patients, and iv if such health care provider is accepting new patients, whether such health care provider is accepting new patients on an outpatient services basis;.
B For hospitals, the hospital name, the hospital type, such as acute, rehabilitation, children's or cancer, the participating hospital location and the hospital's accreditation status; and. C For facilities other than hospitals, by type, the facility name, the facility type, the types of health care services performed at the facility and the participating facility location or locations and telephone number or numbers. A For health care providers, the health care provider's contact information, board certification and any languages other than English spoken by clinical staff, if applicable;.
B Each health carrier shall include with the print directory information under subparagraph A of this subdivision and in the print participating provider directory under subdivision 2 of subsection a of this section a statement that the information provided or included is accurate as of the date of printing, that covered persons or prospective covered persons should consult the health carrier's electronic participating provider directory on such health carrier's Internet web site and that covered persons may call the telephone number on such covered person's insurance card for more information.
Reserved for future use. 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. Cost-sharing re facility fees. Any general business practice that violates the provisions of this section shall constitute an unfair trade practice pursuant to chapter a.
As used in this section, sections 38aa to 38ao, inclusive, and subsection a of section 38as:. On March first annually, the Insurance Commissioner shall submit a report to the Governor and to the joint standing committees of the General Assembly having cognizance of matters relating to public health and insurance, concerning the commissioner's responsibilities under the provisions of sections 38a to 38au, inclusive, 38aaa, 38aa to 38ah, inclusive, and 38a Each managed care organization that files incomplete data, reports or information shall be so informed by the commissioner, shall be given a date by which to remedy such incomplete filing and shall pay said late fee commencing from the new due date.
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 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;.
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C , and make conforming changes; P. For any contract delivered, issued for delivery, renewed, amended or continued in this state, each managed care organization shall:. Such directory shall include, under a separate category or heading, participating advanced practice registered nurses; and. A Allow an enrollee to designate a participating, in-network physician or a participating, in-network advanced practice registered nurse as such enrollee's primary care provider; and.
B Provide notification in accordance with subsection g of section 38af to each such enrollee upon the termination or withdrawal of the enrollee's primary care provider. B , effective January 1, The managed care organization shall also seek input from physicians who are not employees of or consultants, other than to the extent a person is an employee or consultant solely for the purposes of this subsection, to the managed care organization provided the input is not unreasonably withheld.
The managed care organization shall obtain the input in a manner permitting verification by the commissioner and shall document the process by which it obtained the input. Each managed care organization, in developing provider profiles or otherwise measuring health care provider performance, shall: 1 Make allowances for the severity of illness or condition of the patient mix; 2 make allowances for patients with multiple illnesses or conditions; 3 make available to the commissioner documentation of how the managed care organization makes such allowances; and 4 inform enrollees and participating providers, upon request, how the managed care organization considers patient mix when profiling or evaluating providers.
The commissioner may waive the requirements of this subsection for any managed care organization subject to the provisions of section 38a The plan description shall be in plain language as commonly used by the enrollees and consistent with chapter a. The plan description shall be made available to each enrollee and potential enrollee prior to the enrollee's entering into the contract and during any open enrollment period. The plan description shall not contain provisions or statements that are inconsistent with the plan's medical protocols. The plan description shall contain:.
No contract delivered, issued for delivery, renewed, amended or continued in this state between a managed care organization and a participating provider shall prohibit or limit any cause of action or contract rights an enrollee otherwise has.
Each managed care plan that requires a percentage coinsurance payment by the insured shall calculate the insured's 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 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. History: June 18 Sp Sess. Gag clauses prohibited. The commissioner shall develop the consumer report card in a manner permitting consumer comparison across organizations.
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. 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;. As a result of such test marketing, the commissioner may make any necessary modification to its form or substance.
The Insurance Department shall prominently display a link to the consumer report card on the department's Internet web site.
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The commissioner may investigate any such differences to determine whether further action by the commissioner is warranted. Sections 38am and 38an are repealed, effective July 1, Section 38ap is repealed, effective July 1, Each provider, as defined in section 38a, in utilizing laboratories or testing facilities for enrollees in managed care plans that provide coverage for laboratories and testing facilities, shall utilize laboratories or testing facilities covered by the enrollee's managed care plan or notify the enrollee if the provider intends to utilize a laboratory or testing facility not covered by the plan.
The Commissioner of Public Health may request and shall receive any data, report or information filed with the Insurance Commissioner pursuant to the provisions of sections 38a to 38au, inclusive, 38aaa, 38aj, 38ak and 38a The Insurance Commissioner may adopt regulations in accordance with the provisions of chapter 54 to implement the provisions of sections 38a to 38au, inclusive, 38aaa and 38a The commissioner may adopt regulations, in accordance with the provisions of chapter 54, to implement the provisions of this section.
The chairpersons and ranking members of the joint standing committee of the General Assembly having cognizance of matters relating to insurance shall convene, at least two times each year, a group of physicians and managed care organizations, to discuss issues relative to contracting between physicians and managed care organizations, including issues relative to any national settlement agreements, to the extent permitted under such settlement agreements. 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;.
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 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;.
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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. 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.
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;. 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. 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.