Bill Text: CT SB00807 | 2015 | General Assembly | Comm Sub
Bill Title: An Act Concerning Fairness And Efficiency In Health Insurance Contracting.
Spectrum: Committee Bill
Status: (Introduced - Dead) 2015-05-05 - Referred by Senate to Committee on Appropriations [SB00807 Detail]
Download: Connecticut-2015-SB00807-Comm_Sub.html
General Assembly |
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January Session, 2015 |
LCO No. 4216 | ||
*_____SB00807PH____043015____* | |||
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 FAIRNESS AND EFFICIENCY IN HEALTH INSURANCE CONTRACTING.
Be it enacted by the Senate and House of Representatives in General Assembly convened:
Section 1. (NEW) (Effective October 1, 2015) (a) Not later than January 1, 2016, the Insurance Commissioner shall establish a pilot program that requires health insurance companies, health care centers and other entities that deliver, issue for delivery, renew, amend or continue an individual or group health insurance policy or health benefit plan providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 of the general statutes in this state to offer at least one policy or plan with a tiered health care provider network that rewards insureds and enrollees for choosing low-cost, high-quality health care providers by offering lower copayments, deductibles or other out-of-pocket expenses, without limiting the total number of health care providers or restricting the choice of health care providers within the policy or plan. Such pilot program shall run for not less than three years.
(b) (1) The base premium for a tiered provider network policy or plan shall be at least ten per cent lower than the base premium of the health insurance company's, health care center's or other entity's nontiered policy or plan that is most actuarially similar.
(2) Each tiered provider network policy or plan shall only include variations on cost-sharing between health care provider tiers that are reasonable in relation to the premiums charged and shall provide adequate access to covered services at all tier levels including the lowest cost-sharing tier.
(c) The commissioner shall determine the network adequacy for a tiered provider network policy or plan based on the availability of sufficient health care providers in the overall tiered provider network policy or plan.
(d) (1) For the purposes of the pilot program, an insurance company, health care center or other entity may (A) reclassify a health care provider tier, or (B) determine health care provider participation in a tiered provider network policy or plan not more than once per calendar year, except such company, center or other entity may reclassify a health care provider from a higher cost tier to a lower cost tier or add new health care providers to its tiered provider network policy or plan at any time.
(2) If such company, center or other entity reclassifies a health care provider tier or a health care provider during a policy or plan year, it shall notify any insured or enrollee affected by such change at least thirty days before such change takes effect.
(e) The commissioner shall adopt regulations, in accordance with the provisions of chapter 54 of the general statutes, to implement the provisions of this section. Such regulations shall include, but not be limited to, objective quality and cost criteria that health insurance companies, health care centers or other entities subject to subsection (a) of this section shall use to classify a health care provider for tier placement in a tiered provider network policy or plan.
(f) Each health insurance company, health care center or other entity subject to subsection (a) of this section shall post on its Internet web site information about its tiered provider network policy or plan, including, but not limited to, a current list of health care providers participating in such policy or plan, the selection criteria for a health care provider to participate in such policy or plan and, if applicable, the tier under which each participating health care provider is classified.
(g) The commissioner, in consultation with the Healthcare Advocate and the chief executive officer of the Connecticut Health Insurance Exchange, shall annually review and report to the General Assembly on the implementation of the pilot program, including the number of insureds or enrollees for each tiered provider network policy or plan, aggregate demographic information of the insureds or enrollees that is not individually identifiable, geographic information of the insureds or enrollees, utilization trends, premium rates and other costs to insureds and enrollees, the average direct premium claims incurred for a tiered provider network policy or plan compared to nontiered policies or plans, quality of care and outcomes for and satisfaction of the insureds and enrollees. Such report shall include recommendations for any modifications to the program.
Sec. 2. (Effective from passage) Not later than January 1, 2016, the Insurance Commissioner and the Commissioner of Public Health shall jointly develop standard forms for uniform health care billing, health care benefit summaries, out-of-pocket expense explanations, prior authorization requests and any other industry forms for which said commissioners deem uniformity and standardization to be beneficial. Not later than February 1, 2016, said commissioners shall submit any proposed legislation they deem necessary to implement the use of such forms to the joint standing committees of the General Assembly having cognizance of matters relating to insurance and public health.
Sec. 3. Section 19a-646 of the general statutes is repealed and the following is substituted in lieu thereof (Effective October 1, 2015):
(a) As used in this section:
(1) "Office" means the Office of Health Care Access division of the Department of Public Health;
(2) "Fiscal year" means the hospital fiscal year, as used for purposes of this chapter, consisting of a twelve-month period commencing on October first and ending the following September thirtieth;
(3) "Hospital" means any short-term acute care general or children's hospital licensed by the Department of Public Health, including the John Dempsey Hospital of The University of Connecticut Health Center;
(4) "Payer" means any person, legal entity, governmental body or eligible organization that meets the definition of an eligible organization under 42 USC Section 1395mm (b) of the Social Security Act, or any combination thereof, except for Medicare and Medicaid [which] that is or may become legally responsible, in whole or in part for the payment of services rendered to or on behalf of a patient by a hospital. Payer also includes any legal entity whose membership includes one or more payers and any third-party payer; and
(5) "Prompt payment" means payment made for services to a hospital by mail or other means on or before the tenth business day after receipt of the bill by the payer.
(b) No hospital shall bill under the hospital's tax identification number for services provided outside the hospital.
[(b)] (c) No hospital shall provide a discount or different rate or method of reimbursement from the filed rates or charges to any payer except as provided in this section.
[(c)] (d) (1) Any payer may directly negotiate with a hospital for a different rate or method of reimbursement, or both, provided the charges and payments for the payer are on file at the hospital business office in accordance with this subsection. No discount agreement or agreement for a different rate or method of reimbursement, or both, shall be effective until a complete written agreement between the hospital and the payer is on file at the hospital. Each such agreement shall be available to the office for inspection or submission to the office upon request, for at least three years after the close of the applicable fiscal year.
(2) The charges and payments for each payer receiving a discount shall be accumulated by the hospital for each payer and reported as required by the office.
(3) A full written copy of each agreement executed pursuant to this subsection shall be on file in the hospital business office within twenty-four hours of execution.
[(d)] (e) A payer may negotiate with a hospital to obtain a discount on rates or charges for prompt payment.
[(e)] (f) A payer may also negotiate for and may receive a discount for the provision of the following administrative services: (1) A system [which] that permits the hospital to bill the payer through either a computer-processed or machine-readable or similar billing procedure; (2) a system [which] that enables the hospital to verify coverage of a patient by the payer at the time the service is provided; and (3) a guarantee of payment within the scope of the agreement between the patient and the third-party payer for service to the patient prior to the provision of that service.
[(f)] (g) No hospital may require a payer to negotiate for another element or any combination of the above elements of a discount, as established in subsections [(d) and] (e) and (f) of this section, in order to negotiate for or obtain a discount for any single element. No hospital may require a payer to negotiate a discount for all patients covered by such payer in order to negotiate a discount for any patient or group of patients covered by such payer.
[(g)] (h) Any hospital [which] that agrees to provide a discount to a payer under subsection [(d) or] (e) or (f) of this section shall file a copy of the agreement in the hospital's business office and shall provide the same discount to any other payer [who] that agrees to make prompt payment or provide administrative services similar to that contained in the agreement. Each agreement filed shall specify on its face that it was executed and filed pursuant to this subsection.
[(h)] (i) (1) Nothing in this section shall be construed to require payment by any payer or purchaser, under any program or contract for payment or reimbursement of expenses for health care services, for: (A) Services not covered under such program or contract; or (B) that portion of any charge for services furnished by a hospital that exceeds the amount covered by such program or contract.
(2) Nothing in this section shall be construed to supersede or modify any provision of such program or contract that requires payment of a copayment, deductible or enrollment fee or that imposes any similar requirement.
[(i)] (j) A hospital [which] that has established a program approved by the office with one or more banks for the purpose of reducing the hospital's bad debt load, may reduce its published charges for that portion of a patient's bill for services [which] that a payer who is a private individual is or may become legally responsible for, after all other insurers or third-party payers have been assessed their full charges, provided (1) prior to the rendering of such services, the hospital and the individual payer or parent or guardian or custodian have agreed in writing that after receipt of any insurer or third-party payment paid in accordance with the full hospital charges, the remaining payment due from the private individual for such reduced charges shall be made in whole or in part from the balance on deposit in a bank account [which] that has been established by or on behalf of such individual patient, and (2) such payment is made from such account. Nothing in this section shall relieve a patient or legally liable person from being responsible for the full amount of any underpayment of the hospital's authorized charges excluding any discount under this section, by a patient's insurer or any other third-party payer for that insurer's or third-party payer's portion of the bill. Any reduction in charges granted to an individual or parent or guardian or custodian under this subsection shall be reported to the office as a contractual allowance. For purposes of this section "private individual" [shall include] includes a patient's parent, legal guardian or legal custodian but [shall] does not include an insurer or third-party payer.
Sec. 4. (NEW) (Effective October 1, 2015) (a) As used in this section, "hospital" means a facility licensed as a hospital under chapter 368v of the general statutes, and "health system" has the same meaning as provided in section 19a-508c of the general statutes.
(b) Each hospital shall negotiate separately with a health insurance company, health care center or other entity that provides health care benefits to its insureds or enrollees and with health care providers, even if any hospitals are commonly owned.
(c) No hospital or health system shall include in any contract entered into, renewed or amended on or after October 1, 2015, with an insurer, health care center or other entity that provides health care benefits to its insureds or enrollees, any provision that (1) requires such insurer, center or other entity to (A) contract with all the health care provider locations or facilities within the system or for all services the hospital or health system offers, or (B) pay the hospital rate for covered services provided in outpatient facilities or health care providers' offices, or (2) prohibits or limits disclosure of price, cost or claims information.
Sec. 5. (NEW) (Effective October 1, 2015) (a) Each health insurer, health care center, hospital service corporation, medical service corporation, preferred provider network or other entity that contracts with health care providers to provide health care services to its insureds or enrollees, shall include in each such contract that is entered into, renewed or amended on or after October 1, 2015, site-neutral reimbursement policies as recommended by the Medicare Payment Advisory Commission's June 2013, Report to the Congress: Medicare and the Health Care Delivery System, as updated from time to time. Such reimbursement policies shall, at a minimum, (1) require reimbursement that is the same for all health care providers regardless of where the services are performed for the following: (A) Evaluation and management visits; (B) services classified by said commission as Group 1 ambulatory payment classification in said report; and (C) ambulatory surgical procedures and services identified by said commission as appropriate for equal reimbursement, and (2) limit reimbursement differentials to only the amount necessary for the actual cost of packaging ancillary services for services classified by said commission as Group 2 ambulatory payment classification in said report.
(b) Each contract under subsection (a) of this section shall include a conspicuous statement that the contract complies with site-neutral reimbursement policies as required by law.
Sec. 6. Section 38a-472i of the general statutes is repealed. (Effective October 1, 2015)
This act shall take effect as follows and shall amend the following sections: | ||
Section 1 |
October 1, 2015 |
New section |
Sec. 2 |
from passage |
New section |
Sec. 3 |
October 1, 2015 |
19a-646 |
Sec. 4 |
October 1, 2015 |
New section |
Sec. 5 |
October 1, 2015 |
New section |
Sec. 6 |
October 1, 2015 |
Repealer section |
INS |
Joint Favorable |
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PH |
Joint Favorable |