General Assembly		Raised Bill No. 6867
January Session, 2015		LCO No. 3529
		*03529_______INS*
Referred to Committee on INSURANCE AND REAL ESTATE
Introduced by:
(INS)

AN ACT CONCERNING HEALTH CARE PROVIDER NETWORK ADEQUACY.

Be it enacted by the Senate and House of Representatives in General Assembly convened:

Section 1. Section 38a-472f of the general statutes is repealed and the following is substituted in lieu thereof (Effective January 1, 2016):

(a) Each insurer, health care center, managed care organization or other entity that delivers, issues for delivery, renews, amends or continues an individual or group health insurance policy or medical benefits plan, and each preferred provider network, as defined in section 38a-479aa, that contracts with a health care provider, as defined in section 38a-478, for the purposes of providing covered health care services to its enrollees, shall: [maintain a]

(1) Maintain a network of such providers [that is consistent with the National Committee for Quality Assurance's network adequacy requirements or URAC's provider network access and availability standards.] in accordance with the provisions of this section; and

(2) Report annually to the commissioner for each of its policies or plans the number of enrollees and the number of participating in-network health care providers.

(b) (1) The commissioner, in consultation with the Healthcare Advocate, shall assess through actuarial analysis the provider network adequacy of each such insurer, health care center, managed care organization, other entity or preferred provider network. Such assessment shall be done annually at the time of license renewal or at the time of initial licensure and annually thereafter.

(2) No insurer, health care center, managed care organization, other entity or preferred provider network shall exclude from its provider network any appropriately licensed type of health care provider as a class.

(3) Each provider network shall be adequate to meet the comprehensive needs of the enrollees of the insurer, health care center, managed care organization or other entity and provide an appropriate choice of health care providers sufficient to provide the services covered under the policies or plans of such insurer, health care center, managed care organization or other entity. The actuarial analysis required under subdivision (1) of this subsection shall determine (A) whether a network includes a sufficient number of geographically accessible participating health care providers for the number of enrollees in a given region, (B) whether enrollees have the opportunity to select from at least five primary care health care providers within reasonable travel time and distance, taking into account the conditions for provider access in rural areas, (C) whether a network includes sufficient health care providers in each area of specialty practice to meet the needs of the enrollee population, and (D) that such network does not exclude health care providers as set forth in subdivision (2) of this subsection.

(4) In assessing provider network adequacy, the commissioner and the Healthcare Advocate shall consider (A) the availability and accessibility of appropriate and timely care provided to disabled enrollees in accordance with the Americans with Disabilities Act of 1990, 42 USC 12101 et seq., as amended from time to time, (B) the network's capability to provide culturally and linguistically competent care to meet the needs of the enrollee population, and (C) the number of grievances filed pursuant to sections 38a-591c to 38a-591g, inclusive, related to waiting times for appointments, appropriateness of referrals and other indicators of limited network capacity.

(c) (1) If the commissioner believes a provider network is not adequate or that other indicators of limited network capacity exist, the commissioner shall:

(A) Require the insurer, health care center, managed care organization, other entity or preferred provider network to conduct a statistically valid survey of (i) a random sample of in-network health care providers to determine each participating provider's full-time equivalency for a given health plan's enrollees, and (ii) a random sample of enrollees, including new enrollees, who have received services within the three months immediately preceding to determine whether and to what extent such enrollees have had or are having difficulty obtaining timely appointments with in-network health care providers;

(B) Examine the contracting practices of such insurer, health care center, managed care organization, other entity or preferred provider network, including, but not limited to, the willingness of such insurer, health care center, managed care organization, other entity or preferred provider network to enter into good faith negotiations with nonparticipating health care providers. To determine good faith, the commissioner shall interview representatives of such insurer, health care center, managed care organization, other entity or preferred provider network, participating in-network health care providers and health care providers who chose not to contract with such insurer, health care center, managed care organization, other entity or preferred provider network; and

(C) Interview enrollees, including new enrollees, of such insurer, health care center, managed care organization or other entity about such enrollees' experiences in obtaining an appointment with an in-network health care provider.

(2) The commissioner shall approve the methodology used for any survey conducted pursuant to subparagraph (A) of subdivision (1) of this subsection.

(d) The commissioner may conduct or undertake any other activities the commissioner determines are reasonably necessary to assess provider network adequacy of an insurer, health care center, managed care organization, other entity or preferred provider network.

Sec. 2. Section 38a-1041 of the general statutes is amended by adding subsection (h) as follows (Effective January 1, 2016):

(NEW) (h) The Healthcare Advocate shall consult with the Insurance Commissioner as set forth in section 38a-472f, as amended by this act, to assess and ensure health care provider network adequacy.

This act shall take effect as follows and shall amend the following sections:
Section 1	January 1, 2016	38a-472f
Sec. 2	January 1, 2016	38a-1041

Statement of Purpose:

To require insurers, health care centers, managed care organizations or other entities and preferred provider networks to maintain adequate health care provider networks and the Insurance Commissioner, in consultation with the Healthcare Advocate, to assess such network adequacy.

[Proposed deletions are enclosed in brackets. Proposed additions are indicated by underline, except that when the entire text of a bill or resolution or a section of a bill or resolution is new, it is not underlined.]