§ 38a-478c — Managed care organization's report to the commissioner: Data, reports and information required.

Connecticut § 38a-478c

• Jurisdiction: Connecticut
• Title 38a: Insurance
• Ch. 700c: Health Insurance

Text

(a) On or before May first of each year, each managed care organization shall submit to the commissioner: (1) A report on its quality assurance plan that includes, but is not limited to, information on complaints related to providers and quality of care, on decisions related to patient requests for coverage and on prior authorization statistics. Statistical information shall be submitted in a format prescribed by the commissioner and in a manner permitting comparison across plans and shall include, but not be limited to: (A) The ratio of the number of complaints received to the number of enrollees; (B) a summary of the complaints received related to providers and delivery of care or services and the action taken on the complaint; (C) the ratio of the number of prior authorizations denied to the number of prior authorizations requested; (D) a list of health care services that required prior authorization in the prior calendar year; (E) the percentage of services that required prior authorization in the prior calendar year compared to the total overall number of services covered in the prior calendar year; (F) the number of utilization review determinations made by or on behalf of a managed care organization not to certify an admission, service, procedure or extension of stay, and the denials upheld and reversed on appeal within the managed care organization's utilization review procedure; (G) the percentage of those employers or groups that renew their contracts within the previous twelve months; and (H) notwithstanding the provisions of this subsection, on or before July first of each year, all data required by the National Committee for Quality Assurance for its Health Plan Employer Data and Information Set. 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 54. 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 (H) of this subdivision; (2) A model contract that contains the provisions currently in force in contracts between the managed care organization and preferred provider networks in this state, and the managed care organization and participating providers in this state and, upon the commissioner's request, a copy of any individual contracts between such parties, provided the contract may withhold or redact proprietary fee schedule information; (3) A written statement of the types of financial arrangements or contractual provisions that the managed care organization has with hospitals, utilization review companies, physicians, preferred provider networks and any other health care providers including, but not limited to, compensation based on a fee-for-service arrangement, a risk-sharing arrangement or a capitated risk arrangement; (4) Such information as the commissioner deems necessary to complete the consumer report card required pursuant to section 38a-478 l . Such information may include, but need not be limited to: (A) The organization's characteristics, including its model, its profit or nonprofit status, its address and telephone number, the length of time it has been licensed in this and any other state, its number of enrollees and whether it has received any national or regional accreditation; (B) a summary of the information required by subdivision (3) of this subsection, including any change in a plan's rates over the prior three years, its state medical loss ratio and its federal medical loss ratio, as both terms are defined in section 38a-478 l , how it compensates health care providers and its premium level; (C) a description of services, the number of primary care physicians and specialists, the number and nature of participating preferred provider networks and the distribution and number of hospitals, by county; (D) utilization review information, including the name or source of any established medical protocols and the utilization review standards; (E) medical management information, including the provider-to-patient ratio by primary care provider and specialty care provider, the percentage of primary and specialty care providers who are board certified, and how the medical protocols incorporate input as required in section 38a-478e ; (F) the quality assurance information required to be submitted under the provisions of subdivision (1) of subsection (a) of this section; (G) the status of the organization's compliance with the reporting requirements of this section; (H) whether the organization markets to individuals and Medicare recipients; (I) the number of hospital days per thousand enrollees; and (J) the average length of hospital stays for specific procedures, as may be requested by the commissioner; (5) A summary of the procedures used by managed care organizations to credential providers; (6) A report on claims denial data for lives covered in the state for the prior calendar year, in a format prescribed by the commissioner, that includes: (A) The total number of claims received; (B) the total number of claims denied; (C) the total number of denials that were appealed; (D) the total number of denials that were reversed upon appeal; (E) (i) the reasons for the denials, including, but not limited to, “not a covered benefit”, “not medically necessary” and “not an eligible enrollee”, (ii) the total number of times each reason was used, and (iii) the percentage of the total number of denials each reason was used; and (F) other information the commissioner deems necessary; and (7) A report, in a format prescribed by the commissioner, that contains a summary of (A) the actuarial analysis utilized in setting the standards for any procedures subject to prior authorization in the prior calendar year, and (B) any estimated premium savings that resulted from prior authorization and other utilization review protocols used in the prior calendar year. (b) The information required pursuant to subsection (a) of this section shall be consistent with the data required by the National Committee for Quality Assurance (NCQA) for its Health Plan Employer Data and Information Set (HEDIS). (c) The commissioner may accept electronic filing for any of the requirements under this section and may revise such filing requirements to facilitate implementation of the provisions of subdivision (1) of subsection (a) of this section. (d) No managed care organization shall be liable for a claim arising out of the submission of any information concerning complaints concerning providers, provided the managed care organization submitted the information in good faith. (e) The information required under subdivision (6) of subsection (a) of this section shall be posted on the Insurance Department's Internet web site.

Legislative History

(P.A. 97-99, S. 4; P.A. 98-27, S. 19; P.A. 03-169, S. 12; P.A. 09-46, S. 3; P.A. 10-5, S. 16; 10-19, S. 1; P.A. 11-58, S. 51; P.A. 15-118, S. 45, 46; P.A. 23-204, S. 228.) History: P.A. 98-27 amended Subpara. (a)(1)(F) to add “Notwithstanding the provisions of this subsection, on or before July 1, 1998, and annually thereafter” re required data; P.A. 03-169 amended Subsec. (a) to reword Subdiv. (1)(D) re utilization review determinations, to add in Subdivs. (2) and (3) reference to preferred provider networks, to substitute “required” for “he is required to develop and distribute” in Subdiv. (4) and to add “the number and nature of participating preferred provider networks” in Subpara. (C), and make conforming changes; P.A. 09-46 amended Subsec. (a) to make a technical change and, in Subdiv. (4)(B), to replace provision re percentage of total premium revenues with definition of medical loss ratio in Sec. 38a-478 l (b); P.A. 10-5 made a technical change in Subsec. (a)(1), effective May 5, 2010; P.A. 10-19 made a technical change in Subsec. (a)(1), added Subsec. (a)(6) re report on claims denial data and added Subsec. (e) re posting of data on Insurance Department's web site, effective July 1, 2010; P.A. 11-58 amended Subsec. (a) to add federal medical loss ratio to information provided to commissioner to complete consumer report card in Subdiv. (4) and to make technical changes, effective January 1, 2012; P.A. 15-118 made technical changes in Subsec. (a)(1) and (4); P.A. 23-204 amended Subsec. (a) to add “in a format prescribed by the commissioner and” re statistical information in Subdiv. (1), to add a new Subpara. (D) re prior authorization data reporting requirements, to redesignate existing Subparas. (D) to (F) as Subparas. (F) to (H), to add Subdiv. (7) re report on actuarial analyses and premium savings relating to prior authorization and to make conforming changes and amended Subsec. (c) re commissioner may revise filing requirements to facilitate implementation of Subsec. (a)(1).