AN ACT CONCERNING HEALTH CARE AFFORDABILITY.

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General Assembly Substitute Bill No. 3
February Session, 2026

AN ACT CONCERNING HEALTH CARE AFFORDABILITY.
Be it enacted by the Senate and House of Representatives in General
Assembly convened:

Section 1. (NEW) ( Effective July 1, 2026 ) (a) There is established the 1
Connecticut Affordable Health Care Trust Fund. Said fund may contain 2
any moneys required or permitted by law to be deposited in the fund 3
and shall receive and hold all payments and deposits for contributions 4
intended for said fund, as well as gifts, bequests, endowments or 5
federal, state or local grants and any other funds from any public or 6
private source and all earnings until disbursed in accordance with the 7
provisions of this section. 8
(b) The amounts on deposit in said fund shall not constitute property 9
of the state and said fund shall not be construed to be a department, 10
institution or agency of the state. Amounts on deposit in said fund shall 11
not be commingled with state funds and the state shall have no claim to 12
or against, or any interest in, such deposits. Any contract entered into 13
by or any obligation of said fund shall not constitute a debt or obligation 14
of the state and the state shall have no obligation to any person on 15
account of said fund and all amounts obligated to be paid from said 16
fund shall be limited to amounts available for such obligation on deposit 17
in said fund. Said fund shall continue in existence as long as it holds any 18
deposits or has any obligations and until its existence is terminated by 19
law. 20
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(c) Notwithstanding the provisions of sections 3 -13 to 3 -13h, 21
inclusive, of the general statutes, the Treasurer shall invest the amounts 22
on deposit in said fund in a manner reasonable and appropriate to 23
achieve the objectives of said fund, exercising the discretion and care of 24
a prudent person in similar circumstances with similar objectives. The 25
Treasurer shall give due consideration to rate of return, risk, term or 26
maturity, diversification of the total portfolio within said fund, liquidity, 27
the projected disbursements and expenditures and the expected 28
payments, deposits, contributions and gifts to be received. The 29
Treasurer shall not require said fund to invest directly in obligations of 30
the state or any political subdivision of the state or in any investment or 31
other endowment administered by the Treasurer. The assets of said 32
fund shall be continuously invested and reinvested in a manner 33
consistent with the objectives of said fund until expended in accordance 34
with the provisions of this section. 35
(d) The Treasurer, on behalf of said fund and for purposes of said 36
fund, may: 37
(1) Receive and invest moneys in said fund in any instruments, 38
obligations, securities or property in accordance with this section; 39
(2) Enter into one or more contractual agreements, including 40
contracts for legal, actuarial, accounting, custodial, advisory, 41
management, administrative, advertising, marketing and consulting 42
services for said fund and pay for such services from the assets of said 43
fund; 44
(3) Procure insurance in connection with said fund's property, assets, 45
activities or deposits to said fund; 46
(4) Apply for and accept gifts, grants or donations from public or 47
private sources to enable said fund to carry out its objectives; 48
(5) Adopt regulations in accordance with chapter 54 of the general 49
statutes for purposes of this section; 50
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(6) Sue and be sued; 51
(7) Establish one or more accounts within said fund; and 52
(8) Take any other action necessary to carry out the purposes of this 53
section and incidental to the duties imposed on the Treasurer pursuant 54
to this section. 55
(e) Amounts on deposit in the Connecticut Affordable Health Care 56
Trust Fund, if any, shall be used to implement the Connecticut Option 57
affordable health care program established pursuant to section 4 of this 58
act. 59
(f) The Treasurer shall ensure that sufficient liquidity exists within 60
the fund to allow for expenditures in each fiscal year. 61
Sec. 2. Section 3-13c of the 2026 supplement to the general statutes is 62
repealed and the following is substituted in lieu thereof (Effective July 1, 63
2026): 64
As used in sections 3 -13 to 3 -13e, inclusive, and 3 -31b, "trust funds" 65
includes the Connecticut Municipal Employees' Retirement Fund A, the 66
Connecticut Municipal Employees' Retirement Fund B, the Soldiers, 67
Sailors and Marines Fund, the Family and Medical Leave Insurance 68
Trust Fund, the State's Attorneys' Retirement Fund, the Teachers' 69
Annuity Fund, the Teachers' Pension Fund, the Teachers' Survivorship 70
and Dependency Fund, the School Fund, the State Employees 71
Retirement Fund, the Hospital Insurance Fund, the Policemen and 72
Firemen Survivor's Benefit Fund, any trust fund described in 73
subdivision (1) of subsection (b) of section 7 -450 that is administered, 74
held or invested by the State Treasurer, the Connecticut Baby Bond 75
Trust, any Climate Change and Coastal Resiliency Reserve Fund created 76
pursuant to section 7-159d, the Early Childhood Education Endowment, 77
the Connecticut Affordable Health Care Trust Fund established 78
pursuant to section 1 of this act and all other trust funds administered, 79
held or invested by the State Treasurer. 80
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Sec. 3. ( Effective July 1, 2026 ) Notwithstanding the provisions of 81
sections 3 and 4 of special act 26 -1, for the fiscal year ending June 30, 82
2027, the Secretary of the Office of Policy and Management shall transfer 83
two hundred million dollars from the Federal Cuts Response Fund, 84
established pursuant to section 1 of special act 26 -1, to the Connecticut 85
Affordable Health Care Trust Fund established pursuant to section 1 of 86
this act. 87
Sec. 4. (NEW) ( Effective from passage ) (a) As used in this section and 88
section 7 of this act: 89
(1) "Access Health Connecticut" means the Internet web site 90
maintained by the Connecticut Health Insurance Exchange, established 91
pursuant to section 38a -1081 of the general statutes, through which 92
enrollees and prospective enrollees may obtain standardized 93
comparative information on and enroll in qualified health plans under 94
the Affordable Care Act; 95
(2) "Affordable Care Act" and "qualified health plan" have the same 96
meanings as provided in section 38a-1080 of the general statutes; 97
(3) "Affordable health plan" means a qualified health plan with 98
premiums that cost (A) not more than two per cent of household income 99
for persons with household income not exceeding two hundred per cent 100
of the federal poverty level, and (B) not more than eight and one -half 101
per cent of household income for persons with household income that 102
is four hundred per cent or more of the federal poverty level; and 103
(4) "Eligible enrollee" means a resident of the state who is eligible to 104
enroll in a qualified health plan on Access Health Connecticut and (A) 105
has household income not exceeding two hundred per cent of the 106
federal poverty level and is ineligible for the Covered Connecticut 107
program established pursuant to section 19a -754c of the general 108
statutes, or (B) has household income exceeding four hundred per cent 109
of the federal poverty level but not exceeding six hundred per cent of 110
the federal poverty level and is ineligible for federal premium subsidies 111
under the Affordable Care Act. 112
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(b) There is established within the Office of Policy and Management 113
the Connecticut Option affordable health care program for the purpose 114
of creating affordable health insurance coverage. The Secretary of the 115
Office of Policy and Management, in consultation with the 116
Commissioner of Social Services, the Insurance Commissioner and the 117
chief executive officer of the Connecticut Health Insurance Exchange, 118
and subject to the recommendations of the working group established 119
pursuant to section 7 of this act, shall design and implement the 120
Connecticut Option program using moneys from the Connecticut 121
Affordable Health Care Trust Fund established pursuant to section 1 of 122
this act and any other state, federal or other funding sources available 123
to implement the provisions of this section. 124
(c) The Connecticut Option program shall include a state health care 125
premium subsidy to enable an eligible enrollee to obtain an affordable 126
health plan on Access Health Connecticut for the period beginning July 127
1, 2026, and ending December 31, 2027. The program may include, but 128
shall not be limited to: 129
(1) A buy-in option for a health plan that mirrors Medicaid; 130
(2) Other options for subsidies for eligible enrollees or other persons 131
for the purpose of purchasing an affordable health plan; and 132
(3) Additional affordable health care options for persons of all income 133
levels, promoted by means including, but not limited to, authorizing a 134
primary insurer to transfer portions of its risk portfolios to another 135
entity to limit maximum losses and stabilize financial performance. 136
(d) In designing and implementing the Connecticut Option program, 137
the Secretary of the Office of Policy and Management shall adopt the 138
Connecticut Option program recommended by the working group 139
established pursuant to section 7 of this act based on (1) analyses of 140
affordability, (2) projected impact on rates of uninsured persons, (3) 141
protection against adverse selection, (4) comprehensiveness of benefits, 142
and (5) impact on equitable access to health care and sustainability. The 143
secretary may: 144
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(A) Solicit economic analysis of key policy options for affordable 145
health insurance, including, but not limited to, plans that mirror 146
Medicaid, qualified health plans or the state employee health plan, 147
which may include recommended policies to (i) promote cost 148
containment and network adequacy, and (ii) mitigate any impact on the 149
individual health insurance market; 150
(B) Accept gifts, grants and donations, which shall be deposited in 151
the Connecticut Affordable Health Care Trust Fund established 152
pursuant to section 1 of this act, and utilize any other available state or 153
federal funds; and 154
(C) Employ or enter into contracts with actuaries and other 155
professionals and enter into contracts with other state agencies, health 156
carriers or other qualified persons and entities as are necessary. 157
(e) Not later than January 1, 2027, every six months thereafter through 158
January 1, 2030, and annually thereafter, the Secretary of the Office of 159
Policy and Management shall submit a report, in accordance with the 160
provisions of section 11 -4a of the general statutes, to the joint standing 161
committees of the General Assembly having cognizance of matters 162
relating to appropriations and the budgets of state agencies, human 163
services and insurance and real estate. The report shall contain a 164
narrative description of the operations, activities and finances of the 165
Connecticut Option program and any supporting documentation or 166
data. 167
Sec. 5. (NEW) ( Effective from passage ) (a) As used in this section and 168
section 6 of this act: 169
(1) "Affordable Care Act" has the same meaning as provided in 170
section 38a-1080 of the general statutes; 171
(2) "Eligible individual" means a state resident who (A) is under sixty-172
five years of age, (B) has household income exceeding one hundred 173
thirty-three per cent of the federal poverty level but not exceeding two 174
hundred per cent of the federal poverty level, (C) is otherwise ineligible 175
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for medical assistance programs established pursuant to chapter 319v of 176
the general statutes, and (D) is otherwise eligible to enroll in a qualified 177
health plan, as defined in section 38a -1080 of the general statutes, on 178
Access Health Connecticut, as defined in section 4 of this act; and 179
(3) "Basic health program" means a health care program authorized 180
under Section 1331 of the Affordable Care Act for eligible individuals 181
that is funded by federal payments to the state amounting to ninety-five 182
per cent of the health insurance premium tax credits and cost -sharing 183
reductions that would have otherwise been provided to, or on behalf of, 184
eligible individuals under the Affordable Care Act. 185
(b) On and after October 1, 2026, the Commissioner of Social Services, 186
in consultation with the Office of Policy and Management and based 187
upon the recommendations of the working group established pursuant 188
to section 7 of this act, shall seek any necessary approvals from the 189
federal government to establish a basic health program and take all 190
necessary actions to maximize federal funding. 191
(c) The commissioner shall, in accordance with the Affordable Care 192
Act, coordinate the administration of, and provision of benefits under, 193
the basic health program with the state medical assistance programs. To 194
the extent permissible under the Affordable Care Act, medical 195
assistance provided through the basic health program shall include the 196
benefits, limits on cost -sharing and other consumer safeguards that 197
apply to the state medical assistance programs. 198
(d) If the commissioner determines that the cost of medical assistance 199
provided to eligible individuals in the basic health program will exceed 200
federal subsidies, or if changes in federal law, regulations or the 201
administration of federal law or regulations affects funding, eligibility 202
for or administration of the program, the commissioner, in consultation 203
with the Office of Policy and Management, may develop a plan to 204
respond to such changes. To the extent that federal funds received under 205
the Affordable Care Act for the basic health program exceed the cost of 206
medical assistance that would otherwise be provided to eligible 207
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individuals, the commissioner shall use such funds to reduce the 208
premiums and cost -sharing of, or provide additional benefits for, 209
eligible individuals in accordance with 42 USC 18051, as amended from 210
time to time. 211
(e) The Commissioner of Social Services shall forward any 212
application for federal approval of or changes to the basic health 213
program to the joint standing committees of the General Assembly 214
having cognizance of matters relating to appropriations and the budgets 215
of state agencies and human services and to the working group 216
established pursuant to section 7 of this act not later than thirty days 217
before seeking federal approval for the program. 218
(f) Not later than January 1, 2027, every six months thereafter through 219
January 1, 2030, and annually thereafter, the commissioner shall submit 220
a report, in accordance with the provisions of section 11-4a of the general 221
statutes, to the joint standing committees of the General Assembly 222
having cognizance of matters relating to appropriations and the budgets 223
of state agencies, human services and insurance and real estate. The 224
report shall contain a narrative description of the operations, activities 225
and finances of the basic health program for the immediately preceding 226
reporting period and any supporting documentation or data. 227
Sec. 6. (NEW) ( Effective July 1, 2026) There is established an account 228
to be known as the "basic health program account", which shall be a 229
separate, nonlapsing account. The account shall contain any moneys 230
required by law to be deposited in the account. Moneys in the account 231
shall be expended by the Department of Social Services solely for the 232
purposes of operating a basic health program in accordance with the 233
Affordable Care Act. 234
Sec. 7. (NEW) (Effective from passage) (a) The Secretary of the Office of 235
Policy and Management shall establish a working group to oversee the 236
design of the Connecticut Option program established pursuant to 237
section 4 of this act and the basic health program established pursuant 238
to sections 5 and 6 of this act. 239
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(b) The working group shall consist of: 240
(1) The Connecticut Healthcare Advocate, or the advocate's designee; 241
(2) The Insurance Commissioner, or the commissioner's designee; 242
(3) The Commissioner of Social Services, or the commissioner's 243
designee; 244
(4) The executive director of the Commission on Racial Equity in 245
Public Health, or the executive director's designee; 246
(5) The State Comptroller, or the comptroller's designee; 247
(6) The Secretary of the Office of Policy and Management, or the 248
secretary's designee, who shall also serve as a chairperson; 249
(7) The speaker of the House of Representatives, the president pro 250
tempore of the Senate, the majority leader of the House of 251
Representatives, the majority leader of the Senate, the minority leader 252
of the House of Representatives and the minority leader of the Senate, 253
or their designees; 254
(8) The House and Senate chairpersons of the joint standing 255
committee of the General Assembly having cognizance of matters 256
relating to human services, who , along with the Secretary of the Office 257
of Policy and Management, or the secretary's designee , shall serve as 258
chairpersons; 259
(9) The House and Senate chairpersons of the joint standing 260
committee of the General Assembly having cognizance of matters 261
relating to insurance and real estate, or their designees; 262
(10) The chief executive officer of Access Health Connecticut; 263
(11) Three health insurance experts from the nonprofit and academic 264
communities with demonstrated knowledge about health plan design 265
and actuarial practices, appointed by the chairpersons of the working 266
group; and 267
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(12) Any other members the chairpersons deem necessary. 268
(c) Any member of the working group appointed under subdivisions 269
(11) and (12) of subsection (b) of this section may be a member of the 270
General Assembly. All initial appointments to the working group shall 271
be made not later than thirty days after the effective date of this section. 272
If such appointments are not made not later than thirty days after the 273
effective date of this section, the Secretary of the Office of Policy and 274
Management may designate individuals with the required 275
qualifications for the applicable appointment to serve on the working 276
group until such appointments are made. 277
(d) The working group may consult with stakeholders, including, but 278
not limited to, current enrollees in Access Health Connecticut, health 279
care providers, health insurance issuers, health care advocates, 280
researchers, actuaries and nonprofit health care service providers. 281
(e) Members appointed pursuant to subdivisions (11) and (12) of 282
subsection (b) of this section shall serve at the pleasure of the appointing 283
authority and shall continue to serve until their successors are 284
appointed. Any vacancy shall be filled by the appointing authority. 285
(f) A majority of the membership of the working group shall 286
constitute a quorum for the transaction of any business and any decision 287
shall be by a majority vote of those present at a meeting . The 288
chairpersons may establish such committees, subcommittees or other 289
entities as they deem necessary to further the purposes of the working 290
group. The working group may adopt rules of procedure. 291
(g) The members of the working group shall serve without 292
compensation, but shall, within the limits of available funds and subject 293
to the approval of the working group's chairpersons, be reimbursed for 294
expenses necessarily incurred in the performance of their duties. 295
(h) Not later than December 1, 2026, the working group shall submit 296
a report to the joint standing committees of the General Assembly 297
having cognizance of matters relating to appropriations and the budgets 298
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of state agencies, human services and insurance and real estate 299
concerning the group's recommendations for the design and 300
implementation of the Connecticut Option program and the basic health 301
program. Such report shall contain a description of the programs, 302
including, but not limited to, operations and funding for the programs. 303
Sec. 8. ( Effective July 1, 2026 ) Prior to implementation of the 304
Connecticut Option program and the basic health program, the 305
Secretary of the Office of Policy and Management shall hold at least one 306
public hearing for each program and a series of stakeholder engagement 307
meetings with potential stakeholders, including, but not limited to: (1) 308
Representatives of hospitals, health centers, other health care providers, 309
HUSKY Health plan enrollees and Access Health Connecticut enrollees, 310
(2) members of the joint standing committees of the General Assembly 311
having cognizance of matters relating to appropriations and the budgets 312
of state agencies, human services, public health and insurance and real 313
estate, and (3) other persons with health equity and health coverage 314
policy expertise. 315
Sec. 9. Section 46b -37 of the general statutes is repealed and the 316
following is substituted in lieu thereof (Effective July 1, 2026): 317
(a) Any purchase made by either a husband or wife in his or her own 318
name shall be presumed, in the absence of notice to the contrary, to be 319
made by him or her as an individual and he or she shall be liable for the 320
purchase. 321
(b) Notwithstanding the provisions of subsection (a) of this section, it 322
shall be the joint duty of each spouse to support his or her family, and 323
both, except as provided in subsection (d) of this section, shall be liable 324
for: (1) The reasonable and necessary services of a physician or dentist; 325
(2) hospital expenses rendered the husband or wife or minor child while 326
residing in the family of his or her parents; (3) the rental of any dwelling 327
unit actually occupied by the husband and wife as a residence and 328
reasonably necessary to them for that purpose; and (4) any article 329
purchased by either which has in fact gone to the support of the family, 330
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or for the joint benefit of both. 331
(c) Notwithstanding the provisions of subsection (a) of this section, a 332
spouse who abandons his or her spouse without cause shall be liable for 333
the reasonable support of such other spouse while abandoned. 334
(d) Notwithstanding the provisions of subsection (b) of this section, 335
no spouse surviving after the death of a spouse shall be responsible for 336
the medical debt of the deceased spouse not covered by the estate of the 337
deceased spouse that is related to the (1) reasonable and necessary 338
services of a physician or dentist, or (2) hospital expenses. 339
[(d)] (e) No action may be maintained against either spouse under the 340
provisions of this section, either during or after any period of separation 341
from the other spouse, for any liability incurred by the other spouse 342
during the separation, if, during the separation the spouse who is liable 343
for support of the other spouse has provided the other spouse with 344
reasonable support. 345
[(e)] (f) Abandonment without cause by a spouse shall be a defense 346
to any liability pursuant to the provisions of subdivisions (1) to (4), 347
inclusive, of subsection (b) of this section for expenses incurred by and 348
for the benefit of such spouse. Nothing in this subsection shall affect the 349
duty of a parent to support his or her minor child. 350
Sec. 10. (NEW) ( Effective October 1, 2026 ) (a) As used in this section, 351
(1) "hospital" has the same meaning as provided in section 19a -490 of 352
the general statutes, (2) "hospital financial assistance" means any 353
program administered by a hospital or health system, including a bed 354
fund, as defined in section 19a-509b of the general statutes, that reduces, 355
in whole or in part, a patient's liability for the cost of inpatient or 356
outpatient care, and (3) "hospital financial assistance program" means a 357
program in which a participating hospital provides inpatient and 358
outpatient care: 359
(A) At no cost to an uninsured patient with income not exceeding two 360
hundred per cent of the federal poverty level; 361
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(B) Subsidized by hospital financial assistance for an uninsured 362
patient with income exceeding two hundred per cent of the federal 363
poverty level but not exceeding three hundred per cent of the federal 364
poverty level; 365
(C) Subsidized with hospital financial assistance for any patient with 366
income not exceeding four hundred per cent of the federal poverty level 367
who is enrolled in (i) the federal supplemental nutrition assistance 368
program, or (ii) the federal Special Supplemental Food Program for 369
Women, Infants and Children; and 370
(D) For patients with household income under two hundred per cent 371
of the federal poverty level who are deemed ineligible for hospital 372
financial assistance, billed in accordance with a payment schedule 373
amounting to not more than two per cent of such patient's annual 374
household income per year. After a cumulative thirty -six months of 375
payments by such patient, each participating hospital shall consider the 376
patient's hospital bill paid in full and permanently cease any and all 377
collection activities on any balance that remains unpaid. 378
(b) A hospital may opt in to the hospital financial assistance program 379
and be reimbursed pursuant to section 11 of this act. A participating 380
hospital shall not (1) count a patient's assets when determining 381
eligibility for hospital financial assistance, or (2) require the patient to 382
provide proof that the patient's application for benefits under the state 383
medical assistance program, Medicare, emergency Medicaid coverage, 384
other government -funded coverage or insurance through the 385
Connecticut Health Insurance Exchange was denied . A hospital shall 386
use software that conforms to industry standards concerning electronic 387
income verification and may accept one of the following documents to 388
verify income: 389
(A) A copy of the patient's most recent tax return; 390
(B) A copy of the patient's most recent W-2 form and 1099 forms; 391
(C) Copies of the patient's two most recent pay stubs; or 392
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(D) Written income verification from an employer if the patient is 393
paid in cash. 394
(c) A participating hospital shall exempt patients who are 395
experiencing homelessness or are at imminent risk of homelessness 396
from providing documentation pursuant to subsection (b) of this section 397
but may require such patients to provide self-attested information for 398
both a hospital financial assistance screening and hospital financial 399
assistance application. 400
(d) Notwithstanding the provisions of section 19a-509b of the general 401
statutes, a participating hospital shall make information available on the 402
hospital financial assistance program in each of the top non -English 403
languages spoken by five or more per cent of the population that resides 404
in the geographic area served by the hospital. Such information shall (1) 405
be included in all discharge paperwork and on the hospital's Internet 406
web site, (2) contain contact information for the Office of the Healthcare 407
Advocate, and (3) comply with requirements concerning effective 408
communications under the Americans with Disabilities Act, including, 409
but not limited to, communications delivered through relay services, 410
interpretation, large print and braille. 411
Sec. 11. (NEW) ( Effective October 1, 2026 ) (a) As used in this section, 412
"disproportionate share hospital payment" means a Medicaid payment 413
to a hospital that serves a disproportionately large number of Medicaid 414
beneficiaries and uninsured individuals. The Commissioner of Social 415
Services shall amend the Medicaid state plan to use disproportionate 416
share hospital payments to compensate hospitals that participate in the 417
hospital financial assistance program established pursuant to section 10 418
of this act. 419
(b) The Commissioner of Social Services shall establish criteria for a 420
participating hospital to document hospital financial assistance and 421
receive timely payment for such assistance. 422
(c) A hospital aggrieved by a final decision of the commissioner on 423
the validity of such hospital's bills for hospital financial assistance may 424
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file an appeal in accordance with the provisions of section 17b-238 of the 425
general statutes, as amended by this act. 426
Sec. 12. (NEW) (Effective from passage) (a) As used in this section and 427
sections 13 and 15 of this act, "community engagement requirement" 428
means a federal requirement for certain Medicaid beneficiaries to work, 429
participate in a work-related program or community service or enroll in 430
an education program pursuant to Section 71119 of P.L. 119-21. There is 431
established a safety net mitigation working group that shall advise on, 432
monitor and coordinate the state's response to significant changes in 433
federal law or policy that impact public health, social services or other 434
safety net programs. 435
(b) The working group shall consist of the following members: 436
(1) The Secretary of the Office of Policy and Management, or the 437
secretary's designee; 438
(2) The Commissioners of Social Services, Revenue Services, Mental 439
Health and Addiction Services, Developmental Services and Public 440
Health, the Insurance Commissioner and the Labor Commissioner, or 441
their designees; 442
(3) The chairpersons of the joint standing committees of the General 443
Assembly having cognizance of matters relating to appropriations and 444
the budgets of state agencies, human services, housing and insurance 445
and real estate, or their designees, who shall jointly choose the 446
chairpersons of the working group; 447
(4) One person with expertise in health and human services policy 448
administration, one person with expertise in data science, analytics or 449
interagency data integration and one person with expertise in user 450
experience or person -centered design of such programs, all appointed 451
jointly by and serving at the pleasure of the chairpersons of the working 452
group; 453
(5) The chief executive officer of Access Health Connecticut, as 454
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defined in section 4 of this act; 455
(6) The executive director of the Commission on Racial Equity in 456
Public Health; and 457
(7) Any other member that the chairpersons deem necessary. 458
(c) The working group shall: 459
(1) Convene not later than thirty days after the effective date of this 460
section; 461
(2) Review any significant changes in federal law or policy that 462
impact public health, social services or other safety net programs; 463
(3) Evaluate the current or projected operational and fiscal impacts of 464
such changes on agency procurement and service delivery; 465
(4) Recommend budgetary, regulatory, administrative or legislative 466
measures to mitigate adverse procurement or service outcomes to the 467
Office of Policy and Management and the joint standing committees of 468
the General Assembly having cognizance of matters relating to 469
appropriations and the budgets of state agencies, human services, 470
housing and insurance and real estate; and 471
(5) Solicit input from stakeholders, including municipal governments 472
and community -based providers, and independent experts such as 473
academic researchers and policy organizations, as necessary. 474
(d) Not later than February 1, 2027, and annually thereafter, the 475
working group shall submit a report, in accordance with the provisions 476
of section 11-4a of the general statutes, to the joint standing committees 477
of the General Assembly having cognizance of matters relating to 478
appropriations and the budgets of state agencies, human services, 479
housing and insurance and real estate. Such report shall include: 480
(1) An estimate of the number and percentage of Medicaid and 481
supplemental nutrition assistance program beneficiaries in the state 482
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who may qualify for exemptions from work or community engagement 483
requirements imposed by the federal Fiscal Responsibility Act of 2023, 484
P.L. 118-5 and Section 71119 of P.L. 119-21; 485
(2) A review of current state and federal data systems used to 486
determine or verify: 487
(A) Whether an individual qualifies for an exemption from work 488
requirements under the supplemental nutrition assistance program or 489
from community engagement requirements under Medicaid, including 490
exemptions based on disability status or other allowable criteria; and 491
(B) Whether an individual has met the work requirements for the 492
supplemental nutrition assistance program or the community 493
engagement requirements for Medicaid; 494
(3) A review of any application by the state for grants from the Rural 495
Health Transformation Program or federal technical assistance funding; 496
and 497
(4) Recommendations for establishing a structured and sustainable 498
system to support interagency data sharing, beneficiary identification 499
and administrative practices that maximize the application of allowable 500
exemptions under federal law. 501
Sec. 13. (NEW) ( Effective from passage ) The Commissioner of Social 502
Services, in consultation with the Labor Commissioner, shall, not later 503
than thirty days after the effective date of this section, and monthly 504
thereafter, file a report, in accordance with the provisions of section 11-505
4a of the general statutes, with the joint standing committee of the 506
General Assembly having cognizance of matters relating to human 507
services on: 508
(1) Implementation of federal law concerning work and community 509
engagement requirements for Medicaid and supplemental nutrition 510
assistance beneficiaries under P.L. 119-21; 511
(2) The number of beneficiaries who have lost and are expected to 512
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lose eligibility for the supplemental nutrition assistance and Medicaid 513
programs since implementation of such requirements under P.L. 119-21; 514
(3) Copies of any documentation or reporting provided to the federal 515
government related to the new requirements; 516
(4) A list of changes to contracts with existing vendors and requests 517
for proposals for new vendors concerning implementation of the new 518
requirements; 519
(5) A list of data sources being leveraged for automatic verification of 520
work or income status or qualifications for exemptions from the new 521
federal requirements; 522
(6) Records related to how the Department of Social Services will 523
define "medical frailty" pursuant to section 16 of this act for the purposes 524
of potential exemptions from the requirements; 525
(7) Records related to how verification of compliance with the 526
requirements will be streamlined for recipients of supplemental 527
nutrition assistance and Medicaid; 528
(8) A summary of how Medicaid and supplemental nutrition 529
assistance recipients will be engaged in the decision-making process; 530
(9) A long -term plan for ongoing dissemination of information and 531
support for Medicaid and supplemental nutrition assistance recipients 532
and providers to minimize disenrollment of eligible individuals; and 533
(10) Statistics concerning the Department of Social Services' customer 534
service telephone call center, including, but not limited to, average 535
response time to telephone calls by staff, call abandonment rate, level of 536
staff attrition and details on new staff hired in the past fiscal year. 537
Sec. 14. (NEW) (Effective from passage) (a) As used in this section and 538
section 15 of this act: 539
(1) "HUSKY Health program" means the Medicaid and Children's 540
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Health Insurance Program administered by the Department of Social 541
Services pursuant to sections 17b-261 and 17b-292 of the general statutes 542
and any related state plan amendments or waivers approved by the 543
federal Centers for Medicare and Medicaid Services. 544
(2) "SNAP" means the supplemental nutrition assistance program 545
administered by the Department of Social Services pursuant to title 17b 546
of the general statutes and the federal Food and Nutrition Act of 2008, 547
as amended from time to time. 548
(b) Whenever any federal statute, regulation, rule or administrative 549
guidance is enacted, adopted or issued that the Secretary of the Office 550
of Policy and Management, in consultation with the Commissioner of 551
Social Services, determines is likely to significantly affect federal 552
funding levels, program enrollment and eligibility requirements for or 553
administrative operations of the HUSKY Health program or SNAP, the 554
secretary shall send written notice to the joint standing committees of 555
the General Assembly having cognizance of matters relating to 556
appropriations and the budgets of state agencies and human services. 557
The secretary shall include recommendations in the notice of state 558
statutes or regulations that may need to be amended to preserve access 559
to and maximize the number of persons eligible for such programs. 560
(c) The committees may hold a public hearing not later than fourteen 561
days after receiving such notice and any recommendations from the 562
secretary. 563
Sec. 15. (NEW) ( Effective from passage ) (a) The Department of Social 564
Services shall, for the purposes of administering public assistance 565
programs, including, but not limited to, the HUSKY Health program 566
and SNAP, receive or have access to data maintained by other state 567
agencies, including, but not limited to, the Labor Department, the 568
Department of Public Health, the Department of Education and the 569
Office of Higher Education. The department's use of such data shall 570
include, but need not be limited to: 571
(1) Determining whether an individual qualifies for an exemption 572
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from work requirements under SNAP or from Medicaid community 573
engagement requirements; 574
(2) Whe n an individual is not exempt, verifying compliance with 575
applicable work or community engagement requirements; 576
(3) Identifying and implementing any other uses of interagency data 577
that facilitate effective program administration; and 578
(4) Identifying and implementing additional uses of interagency data 579
that streamline eligibility and enrollment processes in order to mitigate 580
new barriers to access caused by changes in federal law. 581
(b) Data accessible to the Department of Social Services pursuant to 582
subsection (a) of this section shall include, but need not be limited to: 583
(1) Employment and wage records maintained by the Labor 584
Department; 585
(2) Vital records, including, but not limited to, records of birth, death, 586
guardianship and dependency, maintained by the Department of Public 587
Health; 588
(3) Enrollment and attendance records from secondary and 589
postsecondary educational institutions, maintained by the State 590
Department of Education or the Office of Higher Education; and 591
(4) Any other data maintained by a state agency that the Department 592
of Social Services determines is necessary to verify exemption eligibility 593
criteria established under federal law or guidance. 594
(c) To the extent permissible under federal law, the Department of 595
Social Services may (1) verify employment and community engagement 596
status of beneficiaries of Medicaid and SNAP using self -attestation by 597
beneficiaries, and (2) waive such requirements for beneficiaries with 598
medical frailty in accordance with the definition and documentation of 599
medical frailty prescribed by the commissioner pursuant to section 16 600
of this act. 601
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(d) The Department of Social Services shall use any such data 602
received pursuant to this section solely for the purposes of: (1) 603
Identifying and verifying whether an individual qualifies for an 604
exemption from work requirements under the supplemental nutrition 605
assistance program or from community engagement requirements 606
under Medicaid; and (2) determining whether an individual has met 607
such work or community engagement requirements in order to facilitate 608
enrollment and automatic renewal of eligibility. No such data shall be 609
disclosed by the department except as otherwise authorized by state or 610
federal law. 611
(e) The department shall notify the joint standing committee of the 612
General Assembly having cognizance of matters relating to human 613
services in writing prior to disclosing any data pursuant to this section. 614
Such notification shall include identification of (1) any person or entity 615
who is the intended recipient of such disclosed data, and (2) the legal 616
authority permitting such disclosure . All data use and data -sharing 617
activities conducted pursuant to this section shall comply with all 618
applicable state and federal laws governing confidentiality, privacy and 619
security, including, but not limited to: 620
(1) The Health Insurance Portability and Accountability Act of 1996 621
(HIPAA), 42 USC 1320d et seq.; 622
(2) The Family Educational Rights and Privacy Act of 1974 (FERPA), 623
20 USC 1232g; 624
(3) 42 CFR Part 2, concerning the confidentiality of substance use 625
disorder treatment records; 626
(4) Section 17b-90 of the general statutes; 627
(5) Section 4-67n of the general statutes; and 628
(6) Any other applicable state or federal law governing data privacy, 629
confidentiality or security. 630
(f) To the extent permissible under federal law, the Department of 631
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Social Services may establish a system under which applicants and 632
beneficiaries of the HUSKY Health program and SNAP are asked, at the 633
time of application or renewal, to provide consent for the department to 634
access and use data maintained by other agencies in order to determine 635
or renew eligibility. 636
(g) The Department of Social Services shall enter into interagency 637
data-sharing agreements with each agency from which data is accessed 638
or received pursuant to this section. Each such agreement shall specify: 639
(1) The categories of data to be shared; 640
(2) The purpose and manner of use of such data; 641
(3) Procedures for ensuring data security and compliance with 642
applicable privacy laws; and 643
(4) Limitations on further use or disclosure of such data. 644
(h) To the extent permissible under federal law and within available 645
appropriations, the Department of Social Services may establish a 646
program to facilitate enrollment in and automatic renewal of eligibility 647
for Medicaid or SNAP by accepting information submitted by 648
employers, nonprofits and other organizations in accordance with 649
federal law, regulation or guidance on behalf of their employees, clients, 650
volunteers or other related parties for the purposes of verifying whether 651
an individual has met work or community engagement requirements. 652
Sec. 16. (Effective from passage) (a) The Commissioner of Social Services 653
shall develop a state definition of "medical frailty" in advance of new 654
federal guidance on use of the classification for the purpose of 655
exemptions from work and community engagement requirements for 656
Medicaid and the supplemental nutrition assistance program. 657
(b) The commissioner shall take into consideration existing 658
definitions in state statutes and regulations relating to similar physical 659
conditions, definitions of medical frailty in other states, related medical 660
codes needed to diagnose such classification and ways to streamline 661
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such classification across programs administered by the commissioner 662
that enroll medically frail individuals. The commissioner shall file a 663
report, in accordance with the provisions of section 11-4a of the general 664
statutes, not later than sixty days after the effective date of this section 665
with the joint standing committee of the General Assembly having 666
cognizance of matters relating to human services on a proposed 667
definition of medical frailty. 668
Sec. 17. (NEW) (Effective July 1, 2026) (a) The Commissioner of Social 669
Services shall submit any proposal to change the fee -for-service 670
Medicaid payment model to a managed care payment model to the joint 671
standing committees of the General Assembly having cognizance of 672
matters relating to human services and appropriations and the budgets 673
of state agencies for approval, denial or modification before 674
implementing such change or seeking any necessary federal approval to 675
implement such change. Not later than thirty days after the date of their 676
receipt of such proposal, such joint standing committees shall hold a 677
public hearing on the proposal. Not later than fifteen days before such 678
hearing, such joint standing committees shall inform the commissioner, 679
in writing, of the date and time of such hearing and invite the 680
commissioner to testify on the reasons for such proposal, including, but 681
not limited to, (1) any costs or benefits to the state, (2) the expected 682
impact on care provided to Medicaid recipients, and (3) the expected 683
impact on Medicaid reimbursements to providers of such care. At the 684
conclusion of such hearing, such joint standing committees shall vote on 685
whether to approve, deny or modify such proposal. The joint standing 686
committees shall advise the commissioner of their approval, denial or 687
modifications, if any, of the commissioner's proposal. If such joint 688
standing committees advise the commissioner of their denial, the 689
commissioner shall not implement the proposal or seek any necessary 690
federal approval to implement the proposal. 691
(b) If such joint standing committees do not concur, the committee 692
chairpersons shall appoint a committee of conference, which shall be 693
composed of three members from each joint standing committee. At 694
least one member appointed from each joint standing committee shall 695
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be a member of the minority party. The report of the committee of 696
conference shall be made to each joint standing committee, which shall 697
vote to accept or reject the report. The report of the committee of 698
conference may not be amended. If one joint standing committee rejects 699
the report of the committee of conference, the proposal shall be deemed 700
denied. If such joint standing committees accept the report, the 701
committee having cognizance of matters relating to appropriations and 702
the budgets of state agencies shall advise the commissioner of their 703
approval, denial or modifications, if any, of the commissioner's 704
proposal. If such joint standing committees do not so advise the 705
commissioner during the thirty -day period, the proposal shall be 706
deemed denied. 707
(c) Any application for a federal waiver, waiver renewal or proposed 708
Medicaid state plan amendment submitted to the federal government 709
by the commissioner to implement a proposal under subsection (a) of 710
this section shall be in accordance with the approval or modifications, if 711
any, of the joint standing committees of the General Assembly having 712
cognizance of matters relating to human services and appropriations 713
and the budgets of state agencies. 714
(d) Thirty days prior to submission of such proposal to such joint 715
standing committees pursuant to subsection (a) of this section, the 716
Commissioner of Social Services shall post a notice that the 717
commissioner intends to seek approval for such proposal on the 718
Department of Social Services' Internet web site, along with a summary 719
of the provisions of such proposal and the manner in which individuals 720
may submit comments. The commissioner shall allow thirty days for 721
written comments on such proposal and shall include all written 722
comments with the submission of such proposal to such joint standing 723
committees. 724
(e) The commissioner shall include with any application for federal 725
approval of such proposal: (1) Any written comments received pursuant 726
to subsection (d) of this section; and (2) any additional written 727
comments submitted to such joint standing committees at such 728
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proceedings. Such joint standing committees shall transmit any such 729
materials to the commissioner for inclusion with any such application 730
for federal approval. 731
Sec. 18. Section 38a -591d of the general statutes is repealed and the 732
following is substituted in lieu thereof (Effective January 1, 2027): 733
(a) (1) Each health carrier shall maintain written procedures for (A) 734
utilization review and benefit determinations, (B) expedited utilization 735
review and benefit determinations with respect to prospective urgent 736
care requests and concurrent review urgent care requests, and (C) 737
notifying covered persons or covered persons' authorized 738
representatives of such review and benefit determinations. Each health 739
carrier shall make such review and benefit determinations within the 740
specified time periods under this section. 741
(2) In determining whether a benefit request shall be considered an 742
urgent care request, an individual acting on behalf of a health carrier 743
shall apply the judgment of a prudent layperson who possesses an 744
average knowledge of health and medicine, except that any benefit 745
request (A) determined to be an urgent care request by a health care 746
professional with knowledge of the covered person's medical condition, 747
or (B) specified under subparagraph (B) or (C) of subdivision (38) of 748
section 38a-591a shall be deemed an urgent care request. 749
(3) (A) At the time a health carrier notifies a covered person, a covered 750
person's authorized representative or a covered person's health care 751
professional of an initial adverse determination that was based, in whole 752
or in part, on medical necessity, of a concurrent or prospective 753
utilization review or of a benefit request, the health carrier shall notify 754
the covered person's health care professional (i) of the opportunity for a 755
conference as provided in subparagraph (B) of this subdivision, and (ii) 756
that such conference shall not be considered a grievance of such initial 757
adverse determination as long as a grievance has not been filed as set 758
forth in subparagraph (B) of this subdivision. 759
(B) After a health carrier notifies a covered person, a covered person's 760
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authorized representative or a covered person's health care professional 761
of an initial adverse determination that was based, in whole or in part, 762
on medical necessity, of a concurrent or prospective utilization review 763
or of a benefit request, the health carrier shall offer a covered person's 764
health care professional the opportunity to confer, at the request of the 765
covered person's health care professional, with a clinical peer of such 766
health carrier, provided such covered person, covered person's 767
authorized representative or covered person's health care professional 768
has not filed a grievance of such initial adverse determination prior to 769
such conference. Such conference shall not be considered a grievance of 770
such initial adverse determination. Such health carrier shall grant such 771
clinical peer the authority to reverse such initial adverse determination. 772
(b) With respect to a nonurgent care request: 773
(1) (A) For a prospective or concurrent review request, a health carrier 774
shall make a determination within a reasonable period of time 775
appropriate to the covered person's medical condition, but not later than 776
[seven calendar] two business days after the date the health carrier 777
receives such request, and shall notify the covered person and, if 778
applicable, the covered person's authorized representative of such 779
determination, whether or not the carrier certifies the provision of the 780
benefit. 781
(B) If the review under subparagraph (A) of this subdivision is a 782
review of a grievance involving a concurrent review request, pursuant 783
to 45 CFR 147.136, as amended from time to time, the treatment shall be 784
continued without liability to the covered person until the covered 785
person has been notified of the review decision. A health carrier shall 786
acknowledge receipt of a nonurgent prior authorization request not 787
later than twenty-four hours after receipt and shall inform the covered 788
person, authorized representative or health care provider, as applicable, 789
at that time if any information is missing that is necessary to make a 790
determination on the request. 791
(C) If a health carrier notifies a covered person, authorized 792
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representative or health care provider pursuant to subparagraph (B) of 793
this subdivision that additional information is necessary, the health 794
carrier shall approve or deny the prior authorization request not later 795
than twenty-four hours after receipt of such information. 796
(2) For a retrospective review request, a health carrier shall make a 797
determination within a reasonable period of time, but not later than 798
thirty calendar days after the date the health carrier receives such 799
request. 800
(3) (A) The time period specified in subdivision (1) of this subsection 801
may be extended once by the health carrier for up to five calendar days, 802
and the time period specified in subdivision (2) of this subsection may 803
be extended once by the health carrier for up to fifteen calendar days , 804
provided the health carrier: 805
(i) Determines that an extension is necessary due to circumstances 806
beyond the health carrier's control; and 807
(ii) Notifies the covered person and, if applicable, the covered 808
person's authorized representative prior to the expiration of the initial 809
time period, of the circumstances requiring the extension of time and 810
the date by which the health carrier expects to make a determination. 811
(B) Notwithstanding the provisions of subparagraph (A) of this 812
subdivision, [(3) of this subsection, ] the time period specified in 813
subdivision (1) of this subsection may be extended once by the health 814
carrier for up to fifteen calendar days, provided the covered person's 815
health care professional notifies the health carrier that the service will 816
not be performed for at least three months from the date such health 817
carrier received the request. 818
(4) (A) If the extension pursuant to subdivision (3) of this subsection 819
is necessary due to the failure of the covered person or the covered 820
person's authorized representative to provide information necessary to 821
make a determination on the request, the health carrier shall: 822
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(i) Specifically describe in the notice of extension the required 823
information necessary to complete the request; and 824
(ii) Provide the covered person and, if applicable, the covered 825
person's authorized representative with not less than forty-five calendar 826
days after the date of receipt of the notice to provide the specified 827
information. 828
(B) If the covered person or the covered person's authorized 829
representative fails to submit the specified information before the end 830
of the period of the extension, the health carrier may deny certification 831
of the benefit requested. 832
(c) With respect to an urgent care request: 833
(1) (A) Unless the covered person or the covered person's authorized 834
representative has failed to provide information necessary for the health 835
carrier to make a determination and except as specified under 836
subparagraph (B) of this subdivision, the health carrier shall make a 837
determination as soon as possible, taking into account the covered 838
person's medical condition, but not later than twenty-four hours after 839
the health carrier receives such request, provided, if the urgent care 840
request is a concurrent review request to extend a course of treatment 841
beyond the initial period of time or the number of treatments, such 842
request is made not less than twenty-four hours prior to the expiration 843
of the prescribed period of time or number of treatments. For an urgent 844
prior authorization request, a health carrier shall approve, deny or 845
inform the covered person, the covered person's authorized 846
representative or the prescribing health care provider if any information 847
is missing from the prior authorization request not later than twenty -848
four hours after receipt of such request. 849
(B) Unless the covered person or the covered person's authorized 850
representative has failed to provide information necessary for the health 851
carrier to make a determination, for an urgent care request specified 852
under subparagraph (B) or (C) of subdivision (38) of section 38a -591a, 853
the health carrier shall make a determination as soon as possible, taking 854
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into account the covered person's medical condition, but not later than 855
twenty-four hours after the health carrier receives such request, 856
provided, if the urgent care request is a concurrent review request to 857
extend a course of treatment beyond the initial period of time or the 858
number of treatments, such request is made not less than twenty-four 859
hours prior to the expiration of the prescribed period of time or number 860
of treatments. 861
(2) (A) If the covered person or the covered person's authorized 862
representative has failed to provide information necessary for the health 863
carrier to make a determination, the health carrier shall notify the 864
covered person or the covered person's representative, as applicable, as 865
soon as possible, but not later than twenty -four hours after the health 866
carrier receives such request. If a health carrier informs a covered 867
person, authorized representative or health care provider that 868
additional information is necessary for the health carrier to make a 869
determination on an urgent prior authorization request, the health 870
carrier shall approve or deny the request not later than twenty -four 871
hours after receipt of the necessary information. 872
(B) The health carrier shall provide the covered person or the covered 873
person's authorized representative, as applicable, a reasonable period of 874
time to submit the specified information, taking into account the 875
covered person's medical condition, but not less than forty -eight hours 876
after notifying the covered person or the covered person's authorized 877
representative, as applicable. 878
(3) The health carrier shall notify the covered person and, if 879
applicable, the covered person's authorized representative of its 880
determination as soon as possible, but not later than forty -eight hours 881
after the earlier of (A) the date on which the covered person and the 882
covered person's authorized representative, as applicable, provides the 883
specified information to the health carrier, or (B) the date on which the 884
specified information was to have been submitted. 885
(d) (1) If a health carrier fails, within the time periods specified in 886
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subsections (b) and (c) of this section, to approve or deny a completed 887
prior authorization request, acknowledge receipt of the request or notify 888
the covered person, authorized representative or health care provider 889
that additional information is required, the prior authorization request 890
shall be deemed approved. Whenever a health carrier receives a review 891
request from a covered person or a covered person's authorized 892
representative that fails to meet the health carrier's filing procedures, the 893
health carrier shall notify the covered person and, if applicable, the 894
covered person's authorized representative of such failure not later than 895
five calendar days after the health carrier receives such request, except 896
that for an urgent care request, the health carrier shall notify the covered 897
person and, if applicable, the covered person's authorized 898
representative of such failure not later than twenty-four hours after the 899
health carrier receives such request. For a nonurgent prospective or 900
concurrent review request, each health carrier shall acknowledge receipt 901
of each such request as soon as practicable, but not later than twenty -902
four hours after the health carrier receives such request, except that such 903
health carrier shall respond in less time if such a response is required by 904
applicable federal law. 905
(2) If the health carrier provides such notice orally, the health carrier 906
shall provide confirmation in writing to the covered person and the 907
covered person's health care professional of record not later than three 908
calendar days after providing the oral notice . No health carrier shall 909
require a health care professional or hospital to submit additional 910
information that was not reasonably available to such health care 911
professional or hospital at the time that such health care professional or 912
hospital filed the prospective or concurrent review request with such 913
health carrier. 914
(e) (1) Any service for which prior authorization was required and 915
received, including deemed approvals, shall be paid in accordance with 916
state and federal prompt payment laws. A health carrier shall pay claims 917
for health care services for which prior authorization was required by 918
and received from the health carrier, including any prior authorization 919
deemed approved pursuant to subsection (d) of this section, except 920
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where: (A) The covered person was not eligible for coverage at the time 921
services were rendered; (B) benefits were exhausted; (C) the prior 922
authorization was based on materially inaccurate information provided 923
by the health care provider; (D) the health carrier has a reasonable belief 924
that fraud or intentional misconduct occurred; or (E) another health 925
carrier is responsible pursuant to coordination of benefits. Prior 926
authorization approval, whether express or deemed approved, shall 927
constitute a binding determination with respect to coverage and 928
payment. Each health carrier shall provide promptly to a covered 929
person and, if applicable, the covered person's authorized 930
representative a notice of an adverse determination. 931
[(1)] (2) Such notice may be provided in writing or by electronic 932
means and shall set forth, in a manner calculated to be understood by 933
the covered person or the covered person's authorized representative: 934
(A) Information sufficient to identify the benefit request or claim 935
involved, including the date of service, if applicable, the health care 936
professional and the claim amount; 937
(B) The specific reason or reasons for the adverse determination, 938
including, upon request, a listing of the relevant clinical review criteria, 939
including professional criteria and medical or scientific evidence and a 940
description of the health carrier's standard, if any, that were used in 941
reaching the denial; 942
(C) Reference to the specific health benefit plan provisions on which 943
the determination is based; 944
(D) A description of any additional material or information necessary 945
for the covered person to perfect the benefit request or claim, including 946
an explanation of why the material or information is necessary to perfect 947
the request or claim; 948
(E) A description of the health carrier's internal grievance process that 949
includes (i) the health carrier's expedited review procedures, (ii) any 950
time limits applicable to such process or procedures, (iii) the contact 951
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information for the organizational unit designated to coordinate the 952
review on behalf of the health carrier, and (iv) a statement that the 953
covered person or, if applicable, the covered person's authorized 954
representative is entitled, pursuant to the requirements of the health 955
carrier's internal grievance process, to receive from the health carrier, 956
free of charge upon request, reasonable access to and copies of all 957
documents, records, communications and other information and 958
evidence regarding the covered person's benefit request; 959
(F) (i) (I) A copy of the specific rule, guideline, protocol or other 960
similar criterion the health carrier relied upon to make the adverse 961
determination, or (II) a statement that a specific rule, guideline, protocol 962
or other similar criterion of the health carrier was relied upon to make 963
the adverse determination and that a copy of such rule, guideline, 964
protocol or other similar criterion will be provided to the covered person 965
free of charge upon request, with instructions for requesting such copy, 966
and (ii) the links to such rule, guideline, protocol or other similar 967
criterion on such health carrier's Internet web site; 968
(G) If the adverse determination is based on medical necessity or an 969
experimental or investigational treatment or similar exclusion or limit, 970
the written statement of the scientific or clinical rationale for the adverse 971
determination and (i) an explanation of the scientific or clinical rationale 972
used to make the determination that applies the terms of the health 973
benefit plan to the covered person's medical circumstances, or (ii) a 974
statement that an explanation will be provided to the covered person 975
free of charge upon request, and instructions for requesting a copy of 976
such explanation; 977
(H) A statement explaining the right of the covered person to contact 978
the commissioner's office or the Office of the Healthcare Advocate at 979
any time for assistance or, upon completion of the health carrier's 980
internal grievance process, to file a civil action in a court of competent 981
jurisdiction. Such statement shall include the contact information for 982
said offices; and 983
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(I) A statement, expressed in language approved by the Healthcare 984
Advocate and prominently displayed on the first page or cover sheet of 985
the notice using a call-out box and large or bold text, that if the covered 986
person or the covered person's authorized representative chooses to file 987
a grievance of an adverse determination, (i) such appeals are sometimes 988
successful, (ii) such covered person or covered person's authorized 989
representative may benefit from free assistance from the Office of the 990
Healthcare Advocate, which can assist such covered person or covered 991
person's authorized representative with the filing of a grievance 992
pursuant to 42 USC 300gg -93, as amended from time to time, (iii) such 993
covered person or covered person's authorized representative is entitled 994
and encouraged to submit supporting documentation for the health 995
carrier's consideration during the review of an adverse determination, 996
including narratives from such covered person or covered person's 997
authorized representative and letters and treatment notes from such 998
covered person's health care professional, and (iv) such covered person 999
or covered person's authorized representative has the right to ask such 1000
covered person's health care professional for such letters or treatment 1001
notes. 1002
[(2)] (3) Upon request pursuant to subparagraph (E) of subdivision 1003
[(1)] (2) of this subsection, the health carrier shall provide such copies in 1004
accordance with subsection (a) of section 38a -591n, as amended by this 1005
act. 1006
(f) If the adverse determination is a rescission, the health carrier shall 1007
include with the advance notice of the application for rescission 1008
required to be sent to the covered person, a written statement that 1009
includes: 1010
(1) Clear identification of the alleged fraudulent act, practice or 1011
omission or the intentional misrepresentation of material fact; 1012
(2) An explanation as to why the act, practice or omission was 1013
fraudulent or was an intentional misrepresentation of a material fact; 1014
(3) A disclosure that the covered person or the covered person's 1015
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authorized representative may file immediately, without waiting for the 1016
date such advance notice of the proposed rescission ends, a grievance 1017
with the health carrier to request a review of the adverse determination 1018
to rescind coverage, pursuant to sections 38a-591e and 38a-591f; 1019
(4) A description of the health carrier's grievance procedures 1020
established under sections 38a -591e and 38a -591f, including any time 1021
limits applicable to those procedures; and 1022
(5) The date such advance notice of the proposed rescission ends and 1023
the date back to which the coverage will be retroactively rescinded. 1024
(g) (1) Whenever a health carrier fails to strictly adhere to the 1025
requirements of this section with respect to making utilization review 1026
and benefit determinations of a benefit request or claim, the covered 1027
person shall be deemed to have exhausted the internal grievance 1028
process of such health carrier and may file a request for an external 1029
review in accordance with the provisions of section 38a-591g, regardless 1030
of whether the health carrier asserts it substantially complied with the 1031
requirements of this section or that any error it committed was de 1032
minimis. 1033
(2) A covered person who has exhausted the internal grievance 1034
process of a health carrier may, in addition to filing a request for an 1035
external review, pursue any available remedies under state or federal 1036
law on the basis that the health carrier failed to provide a reasonable 1037
internal grievance process that would yield a decision on the merits of 1038
the claim. 1039
Sec. 19. Subsection (b) of section 17b -238 of the 2026 supplement to 1040
the general statutes is repealed and the following is substituted in lieu 1041
thereof (Effective October 1, 2026): 1042
(b) Any institution or agency to which payments are to be made 1043
under sections 17b-239 to 17b-246, inclusive, and sections 17b-340, [and] 1044
17b-343 and section 11 of this act which is aggrieved by any decision of 1045
said commissioner may, within ten days after written notice thereof 1046
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from the commissioner, obtain, by written request to the commissioner, 1047
a rehearing on all items of aggrievement. On and after July 1, 1996, a 1048
rehearing shall be held by the commissioner or his designee, provided a 1049
detailed written description of all such items is filed within ninety days 1050
of written notice of the commissioner's decision. The rehearing shall be 1051
held within thirty days of the filing of the detailed written description 1052
of each specific item of aggrievement. The commissioner shall issue a 1053
final decision within sixty days of the close of evidence or the date on 1054
which final briefs are filed, whichever occurs later. Any designee of the 1055
commissioner who presides over such rehearing shall be impartial and 1056
shall not be employed within the Department of Social Services office of 1057
certificate of need and rate setting. Any such items not resolved at such 1058
rehearing to the satisfaction of either such institution or agency or said 1059
commissioner shall be submitted to binding arbitration to an arbitration 1060
board consisting of one member appointed by the institution or agency, 1061
one member appointed by the commissioner and one member 1062
appointed by the Chief Court Administrator from among the retired 1063
judges of the Superior Court, which retired judge shall be compensated 1064
for his services on such board in the same manner as a state referee is 1065
compensated for his services under section 52 -434. The proceedings of 1066
the arbitration board and any decisions rendered by such board shall be 1067
conducted in accordance with the provisions of the Social Security Act, 1068
49 Stat. 620 (1935), 42 USC 1396, as amended from time to time, and 1069
chapter 54. 1070
Sec. 20. Subsection (b) of section 17b -238 of the 2026 supplement to 1071
the general statutes , as amended by section 348 of public act 25 -168, is 1072
repealed and the following is substituted in lieu thereof (Effective January 1073
1, 2027): 1074
(b) Any institution or agency to which payments are to be made 1075
under sections 17b-239 to 17b-246, inclusive, and sections 17b-340, [and] 1076
17b-343 and section 11 of this act which is aggrieved by any decision of 1077
said commissioner may, within ten days after written notice thereof 1078
from the commissioner, obtain, by written request to the commissioner, 1079
a rehearing on all items of aggrievement. On and after July 1, 1996, a 1080
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rehearing shall be held by the commissioner or his designee, provided a 1081
detailed written description of all such items is filed within ninety days 1082
of written notice of the commissioner's decision. The rehearing shall be 1083
held within thirty days of the filing of the detailed written description 1084
of each specific item of aggrievement. The commissioner shall issue a 1085
final decision within sixty days of the close of evidence or the date on 1086
which final briefs are filed, whichever occurs later. Any designee of the 1087
commissioner who presides over such rehearing shall be impartial and 1088
shall not be employed within the Department of Social Services office of 1089
certificate of need and rate setting. Any such items not resolved at such 1090
rehearing to the satisfaction of either such institution or agency or said 1091
commissioner may be appealed in accordance with section 4 -183. Such 1092
appeals shall be privileged cases to be heard by the court as soon after 1093
the return date as shall be practicable. 1094
Sec. 2 1. Subparagraph (C) of subdivision (2) of subsection (a) of 1095
section 38a-591c of the general statutes is repealed and the following is 1096
substituted in lieu thereof (Effective January 1, 2027): 1097
(C) Each health carrier shall (i) post on its Internet web site (I) any 1098
clinical review criteria it uses, and (II) links to any rule, guideline, 1099
protocol or other similar criterion a health carrier may rely upon to make 1100
an adverse determination as described in subparagraph (F) of 1101
subdivision [(1)] (2) of subsection (e) of section 38a-591d, as amended by 1102
this act, and (ii) make its clinical review criteria available upon request 1103
to authorized government agencies. 1104
Sec. 22. Subdivision (1) of subsection (a) of section 38a -591n of the 1105
general statutes is repealed and the following is substituted in lieu 1106
thereof (Effective January 1, 2027): 1107
(a) (1) Upon request pursuant to subparagraph (E) of subdivision [(1)] 1108
(2) of subsection (e) of section 38a -591d, as amended by this act , the 1109
health carrier shall provide free of charge to a covered person or a 1110
covered person's authorized representative, as applicable, copies of all 1111
documents, communications, information and evidence, including 1112
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citations to any medical journals, regarding the covered person's benefit 1113
request that is the subject of the adverse determination that were not 1114
submitted by the covered person or the covered person's authorized 1115
representative and were available to the health carrier or the utilization 1116
review entity that made the adverse determination at the time such 1117
adverse determination was made. 1118
This act shall take effect as follows and shall amend the following
sections:

Section 1 July 1, 2026 New section
Sec. 2 July 1, 2026 3-13c
Sec. 3 July 1, 2026 New section
Sec. 4 from passage New section
Sec. 5 from passage New section
Sec. 6 July 1, 2026 New section
Sec. 7 from passage New section
Sec. 8 July 1, 2026 New section
Sec. 9 July 1, 2026 46b-37
Sec. 10 October 1, 2026 New section
Sec. 11 October 1, 2026 New section
Sec. 12 from passage New section
Sec. 13 from passage New section
Sec. 14 from passage New section
Sec. 15 from passage New section
Sec. 16 from passage New section
Sec. 17 July 1, 2026 New section
Sec. 18 January 1, 2027 38a-591d
Sec. 19 October 1, 2026 17b-238(b)
Sec. 20 January 1, 2027 17b-238(b)
Sec. 21 January 1, 2027 38a-591c(a)(2)(C)
Sec. 22 January 1, 2027 38a-591n(a)(1)

HS Joint Favorable Subst. -LCO
APP Joint Favorable