AN ACT CONCERNING REVIEWS OF HEALTH INSURANCE BENEFITS MANDATED IN THIS STATE.

AN ACT CONCERNING REVIEWS OF HEALTH INSURANCE BENEFITS MANDATED IN THIS STATE.

This bill establishes a health benefit review program within the Insurance Department to evaluate the social and financial impacts of mandated health benefits.

The bill requires the insurance commissioner to review mandated health benefits existing or effective on July 1, 2009. He must report findings to the Insurance and Real Estate Committee by January 1, 2010. It requires the committee, annually by August 1, to give the commissioner a list of any mandated health benefits it wants reviewed. The commissioner must review those benefit and report findings to the committee by the next January 1. The reports must include specified information (see below).

The bill requires the commissioner to contract with the UConn Center for Public Health and Health Policy to conduct the reviews. It authorizes the center's director, as he or she deems appropriate, to (1) retain an actuary, quality improvement clearinghouse, health policy research organization, or other independent expert and (2) engage or consult with any UConn dean, faculty, or other personnel.

The bill requires the Insurance Fund to pay for the review program. It authorizes the commissioner to assess insurers for the program's costs. It specifies that the assessment is in addition to any other taxes, fees, and money the insurers pay to the state. The bill requires the commissioner to deposit payments with the state treasurer, who must credit them to the Insurance Fund as expenses recovered from insurers.

The bill defines “mandated health benefit” as a statutory obligation of, or proposed legislation that would require, an insurer, HMO, hospital or medical service corporation, fraternal benefit society, or other entity offering health insurance or benefits in Connecticut to:

1. allow an insured or plan enrollee to obtain health care treatment or services from a particular type of health care provider;

2. offer or provide coverage for the screening, diagnosis, or treatment of a particular disease or condition; or

3. offer or provide coverage for (a) a particular type of health care treatment or service or (b) medical equipment, medical supplies, or drugs used in connection with a health care treatment or service.

The term includes proposed legislation to expand or repeal an existing health insurance or medical benefit statutory requirement.

The bill requires a mandated health benefit review report to address the benefit's social and financial impacts.

The report must include the social impact of mandating the benefit, including, to the extent available, at least the following:

1. the extent to which a significant portion of the population uses the treatment, service, equipment, supplies, or drugs;

2. the extent to which the treatment, service, or equipment is, or supplies and drugs are, available under Medicare or through public programs that charities, public schools, the Department of Public Health, municipal health departments or districts, or the Department of Social Services administer;

3. the extent to which insurance policies already cover the treatment, service, equipment, supplies, or drugs;

4. if coverage is not generally available, the extent to which this results in (a) people being unable to obtain necessary treatment and (b) unreasonable financial hardships on those needing treatment;

5. the level of demand from the public and health care providers for (a) the treatment, service, equipment, supplies, or drugs and (b) insurance coverage for these;

6. the likelihood of meeting a consumer need based on other states' experiences;

7. relevant findings of state agencies or other appropriate public organizations relating to the benefit's social impact;

8. alternatives to meeting the identified need, including other treatments, methods, or procedures;

9. whether the benefit is (a) a medical or broader social need and (b) consistent with the role of health insurance and managed care concepts;

10. potential social implications regarding the direct or specific creation of a comparable mandated benefit for similar diseases, illnesses, or conditions;

11. the benefit's impact (a) on the availability of other benefits already offered and (b) on employers shifting to self-insured plans;

12. the extent to which employers with self-insured plans offer the benefit;

13. the impact of making the benefit apply to the state employees' health plan; and

14. the extent to which credible scientific evidence published in peer-reviewed medical literature that the relevant medical community generally recognizes determines the treatment, service, equipment, supplies or drugs safe and effective.

The report must include the financial impact of mandating the benefit, including, to the extent available, at least the following:

1. the extent to which the benefit may increase or decrease, over the next five years, (a) the cost of the treatment, service, equipment, supplies, or drugs and (b) the appropriate or inappropriate use of it;

2. the extent to which the treatment, service, or equipment is, or supplies or drugs are, more or less expensive than another that credible scientific evidence published in peer-reviewed medical literature that the relevant medical community generally recognizes is determined to be equally safe and effective;

3. the extent to which the treatment, service, equipment, supplies, or drugs could be an alternative for a more or less expensive one;

4. the reasonably expected increase or decrease of a policyholder's insurance premiums and administrative expenses;

5. methods that will be implemented to manage the benefit's utilization and costs;

6. the impact on the (a) the total cost of health care, including potential savings to insurers and employers resulting from prevention or early detection of disease or illness and (b) cost of health care for small employers and other employers; and

7. the impact on (a) cost-shifting between private and public payors of health care coverage and (b) the overall cost of the state's health care delivery system.