Sec. 19a-754a. Office of Health Strategy established.
Sec. 19a-754c. Covered Connecticut program. Waivers. Prior approval. Reports.
Sec. 19a-754e. Health care expansion study. Report.
Sec. 19a-754h. Payer reporting requirements. Publication of reports.
Secs. 19a-750 to 19a-754. Health Information Technology Exchange of Connecticut; definitions; powers of the authority; board of directors; chief executive officer; grants; advisory committee on patient privacy and security; reports. Establishment of subsidiaries. State pledge to contractors. Tax exemption. Lead health information exchange organization for the state; responsibilities. Sections 19a-750 to 19a-754, inclusive, are repealed, effective July 1, 2014.
(P.A. 09-232, S. 75; P.A. 10-117, S. 82–86; P.A. 11-51, S. 76; 11-242, S. 74; P.A. 12-197, S. 46; P.A. 13-208, S. 9; P.A. 14-217, S. 259.)
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Sec. 19a-754a. Office of Health Strategy established. (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) The Office of Health Strategy shall be responsible for the following:
(1) Developing and implementing a comprehensive and cohesive health care vision for the state, including, but not limited to, a coordinated state health care cost containment strategy;
(2) Promoting effective health planning and the provision of quality health care in the state in a manner that ensures access for all state residents to cost-effective health care services, avoids the duplication of such services and improves the availability and financial stability of such services throughout the state;
(3) Directing and overseeing the State Innovation Model Initiative and related successor initiatives;
(4) (A) Coordinating the state's health information technology initiatives, (B) seeking funding for and overseeing the planning, implementation and development of policies and procedures for the administration of the all-payer claims database program established under section 19a-775a, (C) establishing and maintaining a consumer health information Internet web site under section 19a-755b, and (D) designating an unclassified individual from the office to perform the duties of a health information technology officer as set forth in sections 17b-59f and 17b-59g;
(5) Directing and overseeing the Health Systems Planning Unit established under section 19a-612 and all of its duties and responsibilities as set forth in chapter 368z;
(6) Convening forums and meetings with state government and external stakeholders, including, but not limited to, the Connecticut Health Insurance Exchange, to discuss health care issues designed to develop effective health care cost and quality strategies;
(7) Consulting with the Commissioner of Social Services, Insurance Commissioner and Connecticut Health Insurance Exchange on the Covered Connecticut program described in section 19a-754c; and
(8) (A) Setting an annual health care cost growth benchmark and primary care spending target pursuant to section 19a-754g, (B) developing and adopting health care quality benchmarks pursuant to section 19a-754g, (C) developing strategies, in consultation with stakeholders, to meet such benchmarks and targets developed pursuant to section 19a-754g, (D) enhancing the transparency of provider entities, as defined in subdivision (13) of section 19a-754f, (E) monitoring the development of accountable care organizations and patient-centered medical homes in the state, and (F) monitoring the adoption of alternative payment methodologies in the state.
(c) The Office of Health Strategy shall constitute a successor, in accordance with the provisions of sections 4-38d, 4-38e and 4-39, to the functions, powers and duties of the following:
(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
(2) The Office of the Lieutenant Governor, relating to the (A) development of a chronic disease plan pursuant to section 19a-6q, (B) housing, chairing and staffing of the Health Care Cabinet pursuant to section 19a-725, and (C) (i) appointment of the health information technology officer, and (ii) oversight of the duties of such health information technology officer as set forth in sections 17b-59f and 17b-59g.
(d) Any order or regulation of the entities listed in subdivisions (1) and (2) of subsection (c) of this section that is in force on July 1, 2018, shall continue in force and effect as an order or regulation until amended, repealed or superseded pursuant to law.
(June Sp. Sess. P.A. 17-2, S. 164; P.A. 18-91, S. 1; P.A. 19-56, S. 10; June Sp. Sess. P.A. 21-2, S. 15; P.A. 22-118, S. 217, 251.)
History: June Sp. Sess. P.A. 17-2 effective January 1, 2018; P.A. 18-91 amended Subsec. (b) by deleting reference to July 1, 2018, adding new Subdiv. (2) re promoting effective health planning and provision of quality health care, redesignating existing Subdiv. (2) as Subdiv. (3) and amending same by deleting Subpara. (A) re all-payer claims database program and deleting Subpara. (B) designator, redesignating Subdiv. (3) as Subdiv. (4) and amending same by designating existing provision re coordinating state's health information technology initiatives as Subpara. (A), adding Subparas. (B) to (D) re administration of all-payer claims database program, consumer health information Internet web site, and duties of health information technology officer, respectively, redesignating Subdiv. (4) as Subdiv. (5) and amending same by replacing reference to Office of Health Care Access with reference to Health Systems Planning Unit, and redesignating Subdiv. (5) as Subdiv. (6), and amended Subsec. (c)(2) by deleting reference to Secs. 19a-755, 17b-59 and 17b-59a and adding reference to Sec. 17b-59g, effective May 14, 2018; P.A. 19-56 made a technical change in Subsec. (b)(4), effective June 28, 2019; June Sp. Sess. P.A. 21-2 amended Subsec. (b) by adding Subdiv. (7) re duties re covered Connecticut program under Secs. 19a-754c and 17b-312, effective June 23, 2021; P.A. 22-118 amended Subsec. (b)(7) by eliminating office oversight of Covered Connecticut program, deleting consultation with Commissioner of Social Services and Insurance Commissioner for purposes set forth in Sec. 17b-312, adding consultation with both commissioners and Connecticut Health Insurance Exchange on the Covered Connecticut program and deleting subparagraph designators (A) and (B) and further amended Subsec. (b) by adding Subdiv. (8) re Office of Health Strategy required to set annual cost growth benchmarks, primary care spending target, quality benchmarks, develop strategies to meet benchmarks, enhance transparency of provider entities, monitor development of accountable care organizations and patient-centered medical homes, monitor adoption of alternative payment methodologies and made technical changes, effective May 7, 2022.
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Sec. 19a-754b. Notices to office re sponsor applications to the Food and Drug Administration. Studies of pharmaceutical manufacturers and outpatient prescription drugs. Penalty. Regulations. (a) For the purposes of this section:
(1) “Accelerated approval” has the same meaning as provided in 21 USC 356, as amended from time to time;
(2) “Biologics license application” means an application filed pursuant to Section 601.2 of Title 21 of the Code of Federal Regulations, as amended from time to time;
(3) “Breakthrough therapy” has the same meaning as provided in 21 USC 356, as amended from time to time;
(4) “Drug” has the same meaning as provided in section 21a-92;
(5) “Fast track product” has the same meaning as provided in 21 USC 356, as amended from time to time;
(6) “New drug application” has the same meaning as provided in Section 314.3 of Title 21 of the Code of Federal Regulations, as amended from time to time;
(7) “New molecular entity” has the same meaning as such term is used in 21 USC 355-1, as amended from time to time;
(8) “Orphan drug” has the same meaning as provided in Section 316.3 of Title 21 of the Code of Federal Regulations, as amended from time to time;
(9) “Pipeline drug” means a drug containing a new molecular entity for which a sponsor has filed a new drug application or biologics license application with, and received an action date from, the federal Food and Drug Administration;
(10) “Prescription drug” means a drug prescribed by a health care provider to an individual in this state;
(11) “Priority review” has the same meaning as such term is used in 21 USC 356, as amended from time to time;
(12) “Rebate” has the same meaning as provided in section 38a-479ooo;
(13) “Research and development cost” means a cost that a pharmaceutical manufacturer incurs in researching and developing a new product, process or service, including, but not limited to, a cost that a pharmaceutical manufacturer incurs in researching and developing a product, process or service that the pharmaceutical manufacturer has acquired from another person by license;
(14) “Sponsor” has the same meaning as provided in Section 316.3 of Title 21 of the Code of Federal Regulations, as amended from time to time; and
(15) “Wholesale acquisition cost” has the same meaning as provided in 42 USC 1395w-3a, as amended from time to time.
(b) Beginning on January 1, 2020, each sponsor shall submit to the Office of Health Strategy, established in section 19a-754a, in a form and manner specified by the office, written notice informing the office that such sponsor has filed with the federal Food and Drug Administration:
(1) A new drug application or biologics license application for a pipeline drug, not later than sixty days after such sponsor receives an action date from the federal Food and Drug Administration regarding such application; or
(2) A biologics license application for a biosimilar drug, not later than sixty days after such sponsor's receipt of an action date from the federal Food and Drug Administration regarding such application.
(c) (1) Beginning on January 1, 2020, the executive director of the Office of Health Strategy may conduct a study, with the assistance of the Comptroller and not more frequently than once annually, of each pharmaceutical manufacturer of a pipeline drug that, in the opinion of the executive director in consultation with the Comptroller and the Commissioner of Social Services, may have a significant impact on state expenditures for outpatient prescription drugs. The office may work with the Comptroller to utilize existing state resources and contracts, or contract with a third party, including, but not limited to, an accounting firm, to conduct such study.
(2) Each pharmaceutical manufacturer that is the subject of a study conducted pursuant to subdivision (1) of this subsection shall submit to the office, or any contractor engaged by the office or the Comptroller to perform such study, the following information for the pipeline drug that is the subject of such study:
(A) The primary disease, condition or therapeutic area studied in connection with such drug, and whether such drug is therapeutically indicated for such disease, condition or therapeutic area;
(B) Each route of administration studied for such drug;
(C) Clinical trial comparators, if applicable, for such drug;
(D) The estimated year of market entry for such drug;
(E) Whether the federal Food and Drug Administration has designated such drug as an orphan drug, a fast track product or a breakthrough therapy; and
(F) Whether the federal Food and Drug Administration has designated such drug for accelerated approval and, if such drug contains a new molecular entity, for priority review.
(d) (1) On or before March 1, 2020, and annually thereafter, the executive director of the Office of Health Strategy, in consultation with the Comptroller, Commissioner of Social Services and Commissioner of Public Health, shall prepare a list of not more than ten outpatient prescription drugs that the executive director, in the executive director's discretion, determines are (A) provided at substantial cost to the state, considering the net cost of such drugs, or (B) critical to public health. The list shall include outpatient prescription drugs from different therapeutic classes of outpatient prescription drugs and at least one generic outpatient prescription drug.
(2) The executive director shall not list any outpatient prescription drug under subdivision (1) of this subsection unless the wholesale acquisition cost of the drug, less all rebates paid to the state for such drug during the immediately preceding calendar year, (A) increased by at least (i) twenty per cent during the immediately preceding calendar year, or (ii) fifty per cent during the immediately preceding three calendar years, and (B) was not less than sixty dollars for (i) a thirty-day supply of such drug, or (ii) a course of treatment of such drug lasting less than thirty days.
(3) (A) The pharmaceutical manufacturer of an outpatient prescription drug included on a list prepared by the executive director pursuant to subdivision (1) of this subsection shall provide to the office, in a form and manner specified by the executive director, (i) a written, narrative description, suitable for public release, of all factors that caused the increase in the wholesale acquisition cost of the listed outpatient prescription drug, and (ii) aggregate, company-level research and development costs and such other capital expenditures that the executive director, in the executive director's discretion, deems relevant for the most recent year for which final audited data are available.
(B) The quality and types of information and data that a pharmaceutical manufacturer submits to the office under this subdivision shall be consistent with the quality and types of information and data that the pharmaceutical manufacturer includes in (i) such pharmaceutical manufacturer's annual consolidated report on Securities and Exchange Commission Form 10-K, or (ii) any other public disclosure.
(4) The office shall establish a standardized form for reporting information and data pursuant to this subsection after consulting with pharmaceutical manufacturers. The form shall be designed to minimize the administrative burden and cost of reporting on the office and pharmaceutical manufacturers.
(e) The office may impose a penalty of not more than seven thousand five hundred dollars on a pharmaceutical manufacturer or sponsor for each violation of this section by the pharmaceutical manufacturer or sponsor.
(f) The office may adopt regulations, in accordance with the provisions of chapter 54, to carry out the purposes of this section.
(P.A. 18-41, S. 10.)
History: P.A. 18-41 effective January 1, 2020.
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Sec. 19a-754c. Covered Connecticut program. Waivers. Prior approval. Reports. (a) For the purposes of this section:
(1) “Affordable Care Act” has the same meaning as provided in section 38a-1080;
(2) “Covered Connecticut program” means the program established under subsection (b) of this section;
(3) “Exchange” has the same meaning as provided in section 38a-1080;
(4) “Health carrier” has the same meaning as provided in section 38a-1080;
(5) “Individual market” has the same meaning as provided in 42 USC 18024(a), as amended from time to time;
(6) “Office of Health Strategy” means the Office of Health Strategy established under section 19a-754a; and
(7) “Silver level” has the same meaning as provided in 42 USC 18022(d), as amended from time to time.
(b) There is established within the Department of Social Services the Covered Connecticut program for the purpose of reducing the state's uninsured rate. The Commissioner of Social Services shall administer said program in consultation with the Office of Health Strategy, Insurance Commissioner and exchange, and, as part of said program, the Department of Social Services shall:
(1) Provide premium and cost-sharing subsidies that are sufficient to ensure fully subsidized coverage:
(A) On and after July 1, 2021, for parents and needy caretaker relatives, and their tax dependents not older than twenty-six years of age, who (i) are eligible for premium and cost-sharing subsidies for a qualified health plan, (ii) are ineligible for Medicaid because their income exceeds the Medicaid income limits under chapter 319v, (iii) have household income up to one hundred seventy-five per cent of the federal poverty level, (iv) are receiving coverage under a qualified health plan offered through the exchange in the individual market at a silver level of coverage, and (v) are utilizing the full amount of applicable premium subsidies for such plan;
(B) On and after July 1, 2021, for the following additional family members of parents and caretaker relatives receiving coverage under such qualified health plan, provided the requirements of subparagraph (A) of subdivision (1) of this subsection are met: (i) A child over twenty-six years of age who is permanently and totally disabled, as defined by the Internal Revenue Service pursuant to 26 USC 152, or (ii) a child who is over the age of twenty-six and is incapable of self-sustaining employment by reason of mental or physical handicap and is chiefly dependent upon the parent or caretaker relative for support and maintenance, as described in sections 38a-489 and 38a-512a, or (iii) a child or stepchild receiving coverage under such qualified health plan as described in sections 38a-497 and 38a-512b;
(C) On and after July 1, 2022, for all parents, needy caretaker relatives and low-income adults who (i) are at least nineteen but not more than sixty-four years of age, (ii) are eligible for premium and cost-sharing subsidies for a qualified health plan, (iii) are ineligible for Medicaid because their income exceeds the Medicaid income limits under chapter 319v, (iv) have household income up to one hundred seventy-five per cent of the federal poverty level, (v) are receiving coverage under a qualified health plan offered through the exchange in the individual market at a silver level of coverage, and (vi) are utilizing the full amount of applicable premium subsidies for such plan; and
(D) On and after July 1, 2022, for the following additional family members of parents, caretaker relatives, and adults receiving coverage under such qualified health plan, provided the requirements of subparagraph (C) of subdivision (1) of this subsection are met: (i) A child over twenty-six years of age who is permanently and totally disabled, as defined by the Internal Revenue Service pursuant to 26 USC 152, or (ii) a child who is over the age of twenty-six and is incapable of self-sustaining employment by reason of mental or physical handicap and is chiefly dependent upon the parent or caretaker relative for support and maintenance, as described in sections 38a-489 and 38a-512a, or (iii) a child or stepchild, as described in sections 38a-497 and 38a-512b.
(2) Not earlier than July 1, 2022, provide dental and nonemergency medical transportation services, as provided under chapter 319v, to all eligible individuals described in subdivision (1) of this subsection;
(3) Establish procedures to, on a quarterly basis, pay in reimbursement to each health carrier offering the qualified health plan described in subparagraph (A) or (B) of subdivision (1) of this subsection, as applicable, the premium and cost-sharing subsidies required under subdivision (1) of this subsection to ensure fully subsidized coverage; and
(4) Consult with the Office of Health Strategy and Insurance Commissioner for the purposes set forth in section 17b-312.
(c) (1) The Office of Health Strategy may, subject to the approval required under subdivision (3) of this subsection, seek a waiver pursuant to Section 1332 of the Affordable Care Act, as amended from time to time, to advance the purpose of the Covered Connecticut program. The Office of Health Strategy shall implement such waiver if the federal government issues such waiver.
(2) The Office of Health Strategy shall submit a report, in accordance with section 11-4a, to the joint standing committees of the General Assembly having cognizance of matters relating to appropriations, human services and insurance containing any proposed waiver described in subdivision (1) of this subsection before seeking such waiver from the federal government.
(3) Not later than thirty days after the Office of Health Strategy submits a report under subdivision (2) of this subsection, the joint standing committees of the General Assembly having cognizance of matters relating to appropriations, human services and insurance shall convene a joint public hearing on the proposed waiver contained in the report submitted pursuant to subdivision (2) of this subsection, separately vote to approve or reject such proposed waiver and advise the Office of Health Strategy of their approval or rejection of such proposed waiver. If any committee takes no action on such proposed waiver within the thirty-day period, the proposed waiver shall be deemed rejected.
(d) The benefits and subsidies provided for individuals as part of the Covered Connecticut program shall not be considered income for such individuals for the purposes of chapter 229.
(e) Not later than January 1, 2022, every six months thereafter through January 1, 2024, and annually after January 1, 2024, the Commissioner of Social Services shall submit a report, in accordance with section 11-4a, to the joint standing committees of the General Assembly having cognizance of matters relating to appropriations, human services and insurance. Such report shall contain a description of the operations and finances of, and progress made by, the Covered Connecticut program for the immediately preceding reporting period.
(June Sp. Sess. P.A. 21-2, S. 16; P.A. 22-118, S. 252.)
History: June Sp. Sess. P.A. 21-2 effective June 23, 2021; P.A. 22-118 substituted Department of Social Services for Office of Health Strategy throughout, amended Subsec. (b)(1) by substituting “a qualified health plan” for “the benchmark qualified health plan” and adding clause (v) and Subpara. (B) re utilization of premium subsidies and additional qualified family members, redesignating existing Subpara. (B) as Subpara. (C) and removing “nonpregnant” before “low-income adults”, changing age limits from age 18 to 64 to age 19 to 64, inserting clause (vi) and Subpara. (D), amended Subsec. (b)(2) by substituting individuals qualified pursuant to Subdiv. (1) for parents, needy caretaker relatives and non-pregnant adults who met certain criteria and amended Subsec. (e) by eliminating six-month reports as of January 1, 2024, and requiring annual reports thereafter, effective May 7, 2022.
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Sec. 19a-754d. Collection of demographic data re ancestry or ethnic origin, ethnicity, race or primary language. Inclusion in electronic health record systems. (a) On and after January 1, 2022, any state agency, board or commission that directly, or by contract with another entity, collects demographic data concerning the ancestry or ethnic origin, ethnicity, race or primary language of residents of the state in the context of health care or for the provision or receipt of health care services or for any public health purpose shall:
(1) Collect such data in a manner that allows for aggregation and disaggregation of data;
(2) Expand race and ethnicity categories to include subgroup identities as specified by the Community and Clinical Integration Program of the Office of Health Strategy and follow the hierarchical mapping to align with United States Office of Management and Budget standards;
(3) Provide the option to individuals of selecting one or more ethnic or racial designations and include an “other” designation with the ability to write in identities not represented by other codes;
(4) Provide the option to individuals to refuse to identify with any ethnic or racial designations;
(5) Collect primary language data employing language codes set by the International Organization for Standardization; and
(6) Ensure, in cases where data concerning an individual's ethnic origin, ethnicity or race is reported to any other state agency, board or commission, that such data is neither tabulated nor reported without all of the following information: (A) The number or percentage of individuals who identify with each ethnic or racial designation as their sole ethnic or racial designation and not in combination with any other ethnic or racial designation; (B) the number or percentage of individuals who identify with each ethnic or racial designation, whether as their sole ethnic or racial designation or in combination with other ethnic or racial designations; (C) the number or percentage of individuals who identify with multiple ethnic or racial designations; and (D) the number or percentage of individuals who do not identify or refuse to identify with any ethnic or racial designations.
(b) Each health care provider with an electronic health record system capable of connecting to and participating in the State-wide Health Information Exchange as specified in section 17b-59e shall, collect and include in its electronic health record system self-reported patient demographic data including, but not limited to, race, ethnicity, primary language, insurance status and disability status based upon the implementation plan developed under subsection (c) of this section. Race and ethnicity data shall adhere to standard categories as determined in subsection (a) of this section.
(c) Not later than August 1, 2021, the Office of Health Strategy shall consult with consumer advocates, health equity experts, state agencies and health care providers, to create an implementation plan for the changes required by this section.
(d) The Office of Health Strategy shall (1) review (A) demographic changes in race and ethnicity, as determined by the U.S. Census Bureau, and (B) health data collected by the state, and (2) reevaluate the standard race and ethnicity categories from time to time, in consultation with health care providers, consumers and the joint standing committee of the General Assembly having cognizance of matters relating to public health.
(P.A. 21-35, S. 11.)
History: P.A. 21-35 effective June 14, 2021.
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Sec. 19a-754e. Health care expansion study. Report. (a) The Executive Director of the Office of Health Strategy, in consultation with the Office of Policy and Management, the Department of Social Services, the Connecticut Insurance Department and the Connecticut Health Insurance Exchange established pursuant to section 38a-1081, shall study the feasibility of offering health care coverage for (1) income-eligible children ages nine to eighteen, inclusive, regardless of immigration status, who are not otherwise eligible for Medicaid, the Children's Health Insurance Program, or an offer of affordable employer sponsored insurance as defined in the Affordable Care Act, as an employee or a dependent of an employee, and (2) adults with household income not exceeding two hundred per cent of the federal poverty level who do not otherwise qualify for medical assistance, an offer of affordable, employer-sponsored insurance as defined in the Affordable Care Act, as an employee or a dependent of an employee, or health care coverage through the Connecticut Health Insurance Exchange due to household income.
(b) The study on the feasibility of providing health care coverage to income-eligible children ages nine to eighteen, inclusive, shall include, but not be limited to: (1) The age groups that would be provided medical assistance in each year, and appropriations necessary to provide such assistance, (2) income eligibility criteria and health care coverage consistent with the medical assistance programs established pursuant to sections 17b-261 and 17b-292, and (3) recommendations for identifying and enrolling such children in such coverage.
(c) The study on the feasibility of providing health care coverage for adults with household income not exceeding two hundred per cent of the federal poverty level shall include, but not be limited to: (1) Household income caps for adults who would be provided health care coverage in each year, and appropriations necessary to provide such coverage, (2) health care coverage consistent with the medical assistance programs established pursuant to section 17b-261 and the HUSKY D program as defined in section 17b-290, and (3) recommendations for identifying and enrolling such adults in such coverage.
(d) Not later than July 1, 2022, the executive director shall report, in accordance with the provisions of section 11-4a, on provisions of the feasibility study to the joint standing committees of the General Assembly having cognizance of matters relating to appropriations and the budgets of state agencies, human services and insurance and real estate.
(P.A. 21-176, S. 5.)
History: P.A. 21-176 effective July 12, 2021.
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Sec. 19a-754f. Definitions. For the purposes of this section and sections 19a-754g to 19a-754k, inclusive:
(1) “Drug manufacturer” means the manufacturer of a drug that is: (A) Included in the information and data submitted by a health carrier pursuant to section 38a-479qqq, (B) studied or listed pursuant to subsection (c) or (d) of section 19a-754b, or (C) in a therapeutic class of drugs that the executive director determines, through public or private reports, has had a substantial impact on prescription drug expenditures, net of rebates, as a percentage of total health care expenditures;
(2) “Executive director” means the executive director of the Office of Health Strategy;
(3) “Health care cost growth benchmark” means the annual benchmark established pursuant to section 19a-754g;
(4) “Health care quality benchmark” means an annual benchmark established pursuant to section 19a-754g;
(5) “Health care provider” has the same meaning as provided in subdivision (1) of subsection (a) of section 19a-17b;
(6) “Net cost of private health insurance” means the difference between premiums earned and benefits incurred, and includes insurers' costs of paying bills, advertising, sales commissions, and other administrative costs, net additions or subtractions from reserves, rate credits and dividends, premium taxes and profits or losses;
(7) “Office” means the Office of Health Strategy established under section 19a-754a;
(8) “Other entity” means a drug manufacturer, pharmacy benefits manager or other health care provider that is not considered a provider entity;
(9) “Payer” means a payer, including Medicaid, Medicare and governmental and nongovernment health plans, and includes any organization acting as payer that is a subsidiary, affiliate or business owned or controlled by a payer that, during a given calendar year, pays health care providers for health care services or pharmacies or provider entities for prescription drugs designated by the executive director;
(10) “Performance year” means the most recent calendar year for which data were submitted for the applicable health care cost growth benchmark, primary care spending target or health care quality benchmark;
(11) “Pharmacy benefits manager” has the same meaning as provided in subdivision (10) of section 38a-479ooo;
(12) “Primary care spending target” means the annual target established pursuant to section 19a-754g;
(13) “Provider entity” means an organized group of clinicians that come together for the purposes of contracting, or are an established billing unit that, at a minimum, includes primary care providers, and that collectively, during any given calendar year, has enough attributed lives to participate in total cost of care contracts, even if they are not engaged in a total cost of care contract;
(14) “Potential gross state product” means a forecasted measure of the economy that equals the sum of the (A) expected growth in national labor force productivity, (B) expected growth in the state's labor force, and (C) expected national inflation, minus the expected state population growth;
(15) “Total health care expenditures” means the sum of all health care expenditures in this state from public and private sources for a given calendar year, including: (A) All claims-based spending paid to providers, net of pharmacy rebates, (B) all patient cost-sharing amounts, and (C) the net cost of private health insurance; and
(16) “Total medical expense” means the total cost of care for the patient population of a payer or provider entity for a given calendar year, where cost is calculated for such year as the sum of (A) all claims-based spending paid to providers by public and private payers, and net of pharmacy rebates, (B) all nonclaims payments for such year, including, but not limited to, incentive payments and care coordination payments, and (C) all patient cost-sharing amounts expressed on a per capita basis for the patient population of a payer or provider entity in this state.
(P.A. 22-118, S. 218.)
History: P.A. 22-118 effective May 7, 2022.
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Sec. 19a-754g. Development, publication and modification of health care cost growth benchmarks, primary care spending targets and health care quality benchmarks. (a) Not later than July 1, 2022, the executive director shall publish (1) the health care cost growth benchmarks and annual primary care spending targets as a percentage of total medical expenses for the calendar years 2021 to 2025, inclusive, and (2) the annual health care quality benchmarks for the calendar years 2022 to 2025, inclusive, on the office's Internet web site.
(b) (1) (A) Not later than July 1, 2025, and every five years thereafter, the executive director shall develop and adopt annual health care cost growth benchmarks and annual primary care spending targets for the succeeding five calendar years for provider entities and payers.
(B) In developing the health care cost growth benchmarks and primary care spending targets pursuant to this subdivision, the executive director shall consider (i) any historical and forecasted changes in median income for individuals in the state and the growth rate of potential gross state product, (ii) the rate of inflation, and (iii) the most recent report prepared by the executive director pursuant to subsection (b) of section 19a-754h.
(C) (i) The executive director shall hold at least one informational public hearing prior to adopting the health care cost growth benchmarks and primary care spending targets for each succeeding five-year period described in this subdivision. The executive director may hold informational public hearings concerning any annual health care cost growth benchmark and primary care spending target set pursuant to subsection (a) or subdivision (1) of subsection (b) of this section. Such informational public hearings shall be held at a time and place designated by the executive director in a notice prominently posted by the executive director on the office's Internet web site and in a form and manner prescribed by the executive director. The executive director shall make available on the office's Internet web site a summary of any such informational public hearing and include the executive director's recommendations, if any, to modify or not to modify any such annual benchmark or target.
(ii) If the executive director determines, after any informational public hearing held pursuant to this subparagraph, that a modification to any health care cost growth benchmark or annual primary care spending target is, in the executive director's discretion, reasonably warranted, the executive director may modify such benchmark or target.
(iii) The executive director shall annually (I) review the current and projected rate of inflation, and (II) include on the office's Internet web site the executive director's findings of such review, including the reasons for making or not making a modification to any applicable health care cost growth benchmark. If the executive director determines that the rate of inflation requires modification of any health care cost growth benchmark adopted under this section, the executive director may modify such benchmark. In such event, the executive director shall not be required to hold an informational public hearing concerning such modified health care cost growth benchmark.
(D) The executive director shall post each adopted health care cost growth benchmark and annual primary care spending target on the office's Internet web site.
(E) Notwithstanding the provisions of subparagraphs (A) to (D), inclusive, of this subdivision, if the average annual health care cost growth benchmark for a succeeding five-year period described in this subdivision differs from the average annual health care cost growth benchmark for the five-year period preceding such succeeding five-year period by more than one-half of one per cent, the executive director shall submit the annual health care cost growth benchmarks developed for such succeeding five-year period to the joint standing committee of the General Assembly having cognizance of matters relating to insurance for the committee's review and approval. The committee shall be deemed to have approved such annual health care cost growth benchmarks for such succeeding five-year period, except upon a vote to reject such benchmarks by the majority of committee members at a meeting of such committee called for the purpose of reviewing such benchmarks and held not later than thirty days after the executive director submitted such benchmarks to such committee. If the committee votes to reject such benchmarks, the executive director may submit to the committee modified annual health care cost growth benchmarks for such succeeding five-year period for the committee's review and approval in accordance with the provisions of this subparagraph. The executive director shall not be required to hold an informational public hearing concerning such modified benchmarks. Until the joint standing committee of the General Assembly having cognizance of matters relating to insurance approves annual health care cost growth benchmarks for the succeeding five-year period, such benchmarks shall be deemed to be equal to the average annual health care cost growth benchmark for the preceding five-year period.
(2) (A) Not later than July 1, 2025, and every five years thereafter, the executive director shall develop and adopt annual health care quality benchmarks for the succeeding five calendar years for provider entities and payers.
(B) In developing annual health care quality benchmarks pursuant to this subdivision, the executive director shall consider (i) quality measures endorsed by nationally recognized organizations, including, but not limited to, the National Quality Forum, the National Committee for Quality Assurance, the Centers for Medicare and Medicaid Services, the Centers for Disease Control, the Joint Commission and expert organizations that develop health equity measures, and (ii) measures that: (I) Concern health outcomes, overutilization, underutilization and patient safety, (II) meet standards of patient-centeredness and ensure consideration of differences in preferences and clinical characteristics within patient subpopulations, and (III) concern community health or population health.
(C) (i) The executive director shall hold at least one informational public hearing prior to adopting the health care quality benchmarks for each succeeding five-year period described in this subdivision. The executive director may hold informational public hearings concerning the quality measures the executive director proposes to adopt as health care quality benchmarks. Such informational public hearings shall be held at a time and place designated by the executive director in a notice prominently posted by the executive director on the office's Internet web site and in a form and manner prescribed by the executive director. The executive director shall make available on the office's Internet web site a summary of any such informational public hearing and include the executive director's recommendations, if any, to modify or not modify any such health care quality benchmark.
(ii) If the executive director determines, after any informational public hearing held pursuant to this subparagraph, that modifications to any health care quality benchmarks are, in the executive director's discretion, reasonably warranted, the executive director may modify such quality benchmarks. The executive director shall not be required to hold an additional informational public hearing concerning such modified quality benchmarks.
(D) The executive director shall post each adopted health care quality benchmark on the office's Internet web site.
(c) The executive director may enter into such contractual agreements as may be necessary to carry out the purposes of this section, including, but not limited to, contractual agreements with actuarial, economic and other experts and consultants.
(P.A. 22-118, S. 219.)
History: P.A. 22-118 effective May 7, 2022.
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Sec. 19a-754h. Payer reporting requirements. Publication of reports. (a) Not later than August 15, 2022, and annually thereafter, each payer shall report to the executive director, in a form and manner prescribed by the executive director, for the preceding or prior years, if the executive director so requests based on material changes to data previously submitted, aggregated data, including aggregated self-funded data as applicable, necessary for the executive director to calculate total health care expenditures, primary care spending as a percentage of total medical expenses and net cost of private health insurance. Each payer shall also disclose, as requested by the executive director, payer data required for adjusting total medical expense calculations to reflect changes in the patient population.
(b) Not later than March 31, 2023, and annually thereafter, the executive director shall prepare and post on the office's Internet web site, a report concerning the total health care expenditures utilizing the total aggregate medical expenses reported by payers pursuant to subsection (a) of this section, including, but not limited to, a breakdown of such population-adjusted total medical expenses by payer and provider entities. The report may include, but shall not be limited to, information regarding the following:
(1) Trends in major service category spending;
(2) Primary care spending as a percentage of total medical expenses;
(3) The net cost of private health insurance by payer by market segment, including individual, small group, large group, self-insured, student and Medicare Advantage markets; and
(4) Any other factors the executive director deems relevant to providing context on such data, which shall include, but not be limited to, the following factors: (A) The impact of the rate of inflation and rate of medical inflation; (B) impacts, if any, on access to care; and (C) responses to public health crises or similar emergencies.
(c) The executive director shall annually submit a request to the federal Centers for Medicare and Medicaid Services for the unadjusted total medical expenses of Connecticut residents.
(d) Not later than August 15, 2023, and annually thereafter, each payer or provider entity shall report to the executive director in a form and manner prescribed by the executive director, for the preceding year, and for prior years if the executive director so requests based on material changes to data previously submitted, on the health care quality benchmarks adopted pursuant to section 19a-754g.
(e) Not later than March 31, 2024, and annually thereafter, the executive director shall prepare and post on the office's Internet web site, a report concerning health care quality benchmarks reported by payers and provider entities pursuant to subsection (d) of this section.
(f) The executive director may enter into such contractual agreements as may be necessary to carry out the purposes of this section, including, but not limited to, contractual agreements with actuarial, economic and other experts and consultants.
(P.A. 22-118, S. 220.)
History: P.A. 22-118 effective May 7, 2022.
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Sec. 19a-754i. Meetings between payer or provider and executive director. Criteria for identification of entities exceeding health care cost growth benchmark. (a)(1) For each calendar year, beginning on January 1, 2023, the executive director shall, if the payer or provider entity subject to the cost growth benchmark or primary care spending target so requests, meet with such payer or provider entity to review and validate the total medical expenses data collected pursuant to section 19a-754h for such payer or provider entity. The executive director shall review information provided by the payer or provider entity and, if deemed necessary, amend findings for such payer or provider prior to the identification of payer or provider entities that exceeded the health care cost growth benchmark or failed to meet the primary care spending target for the performance year as set forth in section 19a-754h. The executive director shall identify, not later than May first of such calendar year, each payer or provider entity that exceeded the health care cost growth benchmark or failed to meet the primary care spending target for the performance year.
(2) For each calendar year beginning on or after January 1, 2024, the executive director shall, if the payer or provider entity subject to the health care quality benchmarks for the performance year so requests, meet with such payer or provider entity to review and validate the quality data collected pursuant to section 19a-754h for such payer or provider entity. The executive director shall review information provided by the payer or provider entity and, if deemed necessary, amend findings for such payer or provider prior to the identification of payer or provider entities that exceeded the health care quality benchmark as set forth in section 19a-754h. The executive director shall identify, not later than May first of such calendar year, each payer or provider entity that exceeded the health care quality benchmark for the performance year.
(3) Not later than thirty days after the executive director identifies each payer or provider entity pursuant to subdivisions (1) and (2) of this subsection, the executive director shall send a notice to each such payer or provider entity. Such notice shall be in a form and manner prescribed by the executive director, and shall disclose to each such payer or provider entity:
(A) That the executive director has identified such payer or provider entity pursuant to subdivision (1) or (2) of this subsection; and
(B) The factual basis for the executive director's identification of such payer or provider entity pursuant to subdivision (1) or (2) of this subsection.
(b) (1) For each calendar year beginning on and after January 1, 2023, if the executive director determines that the annual percentage change in total health care expenditures for the performance year exceeded the health care cost growth benchmark for such year, the executive director shall identify, not later than May first of such calendar year, any other entity that significantly contributed to exceeding such benchmark. Each identification shall be based on:
(A) The report prepared by the executive director pursuant to subsection (b) of section 19a-754h for such calendar year;
(B) The report filed pursuant to section 38a-479ppp for such calendar year;
(C) The information and data reported to the office pursuant to subsection (d) of section 19a-754b for such calendar year;
(D) Information obtained from the all-payer claims database established under section 19a-755a; and
(E) Any other information that the executive director, in the executive director's discretion, deems relevant for the purposes of this section.
(2) The executive director shall account for costs, net of rebates and discounts, when identifying other entities pursuant to this section.
(P.A. 22-118, S. 221.)
History: P.A. 22-118 effective May 7, 2022.
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Sec. 19a-754j. Informational public hearings. Participation by significant contributors. Executive director's report. (a)(1) Not later than June 30, 2023, and annually thereafter, the executive director shall hold an informational public hearing to compare the growth in total health care expenditures in the performance year to the health care cost growth benchmark established pursuant to section 19a-754g for such year. Such hearing shall involve an examination of:
(A) The report most recently prepared by the executive director pursuant to subsection (b) of section 19a-754h;
(B) The expenditures of provider entities and payers, including, but not limited to, health care cost trends, primary care spending as a percentage of total medical expenses and the factors contributing to such costs and expenditures; and
(C) Any other matters that the executive director, in the executive director's discretion, deems relevant for the purposes of this section.
(2) The executive director may require any payer or provider entity that, for the performance year, is found to be a significant contributor to health care cost growth in the state or has failed to meet the primary care spending target, to participate in such hearing. Each such payer or provider entity that is required to participate in such hearing shall provide testimony on issues identified by the executive director and provide additional information on actions taken to reduce such payer's or entity's contribution to future state-wide health care costs and expenditures or to increase such payer's or provider entity's primary care spending as a percentage of total medical expenses.
(3) The executive director may require that any other entity that is found to be a significant contributor to health care cost growth in this state during the performance year participate in such hearing. Any other entity that is required to participate in such hearing shall provide testimony on issues identified by the executive director and provide additional information on actions taken to reduce such other entity's contribution to future state-wide health care costs. If such other entity is a drug manufacturer, and the executive director requires that such drug manufacturer participate in such hearing with respect to a specific drug or class of drugs, such hearing may, to the extent possible, include representatives from at least one brand-name manufacturer, one generic manufacturer and one innovator company that is less than ten years old.
(4) Not later than October 15, 2023, and annually thereafter, the executive director shall prepare and submit a report, in accordance with section 11-4a, to the joint standing committees of the General Assembly having cognizance of matters relating to insurance and public health. Such report shall be based on the executive director's analysis of the information submitted during the most recent informational public hearing conducted pursuant to this subsection and any other information that the executive director, in the executive director's discretion, deems relevant for the purposes of this section, and shall:
(A) Describe health care spending trends in this state, including, but not limited to, trends in primary care spending as a percentage of total medical expense, and the factors underlying such trends;
(B) Include the findings from the report prepared pursuant to subsection (b) of section 19a-754h;
(C) Describe a plan for monitoring any unintended adverse consequences resulting from the adoption of cost growth benchmarks and primary care spending targets and the results of any findings from the implementation of such plan; and
(D) Disclose the executive director's recommendations, if any, concerning strategies to increase the efficiency of the state's health care system, including, but not limited to, any recommended legislation concerning the state's health care system.
(b) (1) Not later than June 30, 2024, and annually thereafter, the executive director shall hold an informational public hearing to compare the performance of payers and provider entities in the performance year to the quality benchmarks established for such year pursuant to section 19a-754g. Such hearing shall include an examination of:
(A) The report most recently prepared by the executive director pursuant to subsection (e) of section 19a-754h; and
(B) Any other matters that the executive director, in the executive director's discretion, deems relevant for the purposes of this section.
(2) The executive director may require any payer or provider entity that failed to meet any health care quality benchmarks in this state during the performance year to participate in such hearing. Each such payer or provider entity that is required to participate in such hearing shall provide testimony on issues identified by the executive director and provide additional information on actions taken to improve such payer's or provider entity's quality benchmark performance.
(3) Not later than October 15, 2024, and annually thereafter, the executive director shall prepare and submit a report, in accordance with section 11-4a, to the joint standing committees of the General Assembly having cognizance of matters relating to insurance and public health. Such report shall be based on the executive director's analysis of the information submitted during the most recent informational public hearing conducted pursuant to this subsection and any other information that the executive director, in the executive director's discretion, deems relevant for the purposes of this section, and shall:
(A) Describe health care quality trends in this state and the factors underlying such trends;
(B) Include the findings from the report prepared pursuant to subsection (e) of section 19a-754h; and
(C) Disclose the executive director's recommendations, if any, concerning strategies to improve the quality of the state's health care system, including, but not limited to, any recommended legislation concerning the state's health care system.
(P.A. 22-118, S. 222.)
History: P.A. 22-118 effective May 7, 2022.
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Sec. 19a-754k. Health care cost growth and quality benchmarks and primary care spending targets: Regulations. The executive director may adopt regulations, in accordance with chapter 54, to implement the provisions of section 19a-754a and sections 19a-754f to 19a-754j, inclusive.
(P.A. 22-118, S. 223.)
History: P.A. 22-118 effective May 7, 2022.
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