AN ACT CONCERNING HEALTH COVERAGE.

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General Assembly Raised Bill No. 342
February Session, 2026 LCO No. 2248

Referred to Committee on INSURANCE AND REAL ESTATE

Introduced by:
(INS)

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

Section 1. (NEW) ( Effective July 1, 2026 ) (a) Each insurer, health care 1
center, hospital service corporation, medical service corporation, 2
preferred provider network or other entity that enters into, renews or 3
amends a contract with a health care provider on or after July 1, 2026, to 4
provide covered benefits to insureds or enrollees in this state shall 5
include in such contract: 6
(1) A provision requiring such insurer, health care center, hospital 7
service corporation, medical service corporation, preferred provider 8
network or other entity to: 9
(A) Reimburse the contracting health care provider for a covered 10
outpatient benefit that uses a current procedural terminology 11
evaluation and management (CPT E/M) code, current procedural 12
terminology assessment and management (CPT A/M) code, telehealth 13
codes or drug infusion code in an amount that does not vary based on 14
the facility where the contracting health care provider provides such 15
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benefit; and 16
(B) Use equal reimbursement rates for all contracting health care 17
providers in the same geographic region, as determined by the 18
Insurance Commissioner, and regardless of the employer or affiliation 19
of any contracting health care provider, for each covered outpatient 20
benefit described in subparagraph (A) of this subdivision if the 21
reimbursement for such covered outpatient benefit is made on a fee-for-22
benefit basis or on the basis of bundled benefits per diagnosis, condition, 23
procedure or another standardized bundle of health care benefits; and 24
(2) A conspicuous statement that such contract complies with the 25
provisions of subdivision (1) of this subsection. 26
(b) The Insurance Commissioner shall adopt regulations, in 27
accordance with the provisions of chapter 54 of the general statutes, to 28
implement the provisions of this section. 29
Sec. 2. Subdivision (2) of subsection (a) of section 38a -477i of the 30
general statutes is repealed and the following is substituted in lieu 31
thereof (Effective October 1, 2026): 32
(2) "Anti-steering clause" means any provision , including, but not 33
limited to, utilization management provisions, in a health care contract 34
that restricts the ability of the health carrier or health plan administrator 35
from encouraging an enrollee to obtain a health care service from a 36
competitor of a hospital or health system, including offering incentives 37
to encourage enrollees to utilize specific health care providers such as 38
centers of excellence or any other pay-for-performance program; 39
Sec. 3. ( Effective from passage ) The Insurance Commissioner shall 40
conduct a study concerning various revisions to the insurance statutes, 41
including, but not limited to, statutes concerning (1) excess insurance, 42
(2) the Health Care Cabinet, and (3) outpatient health care services, 43
including, injections and infusions, provided at a hospital-based facility 44
located off-site from a hospital campus . Not later than January 1, 2027, 45
the commissioner shall submit a report, in accordance with the 46
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provisions of section 11 -4a of the general statutes, to the joint standing 47
committee of the General Assembly having cognizance of matters 48
relating to insurance on the results and recommendations of such study. 49
Sec. 4. (NEW) ( Effective October 1, 2026 ) (a) For purposes of this 50
section, "clinical peer" has the same meaning as provided in section 38a-51
591a of the general statutes, "health carrier" has the same meaning as 52
provided in section 38a -1080 of the general statutes and "downcode" 53
means any adjustment of a health benefit claim by any insurer, health 54
care center, hospital service corporation, medical service corporation, 55
preferred provider network or other entity to a less complex or lower 56
cost billing code in order to provide a lower reimbursement to a health 57
care provider for such health benefit claim than is required for the actual 58
service performed pursuant to such contract between such health care 59
provider and such entity. 60
(b) No health carrier shall use a software tool, including, but not 61
limited to, artificial intelligence or an algorithm, to automatically 62
downcode or deny a health insurance claim submitted by a health care 63
provider without review by a clinical peer. 64
Sec. 5. Subparagraph (C) of subdivision (1) of subsection (g) of section 65
38a-472f of the general statutes is repealed and the following is 66
substituted in lieu thereof (Effective October 1, 2026): 67
(C) For each contract entered into, renewed, amended or continued 68
on or after July 1, 2023, between a health carrier and a participating 69
provider that is a hospital, as defined in section 38a -493, or a parent 70
corporation of a hospital or an intermediary of a hospital, if the contract 71
is not renewed or is terminated by either the health carrier or the 72
participating provider, the health carrier and the participating provider 73
shall continue to abide by the terms of such contract, including 74
reimbursement terms for all health care services and provisions 75
provided under such contract, [for a period of sixty days from the date 76
of termination or, in the case of a nonrenewal, from the end of the 77
contract period. Except as otherwise agreed between such health carrier 78
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and such participating provider, the reimbursement terms of any 79
contract entered into by such health carrier and such participating 80
provider during said sixty-day period shall be retroactive to the date of 81
termination or, in the case of a nonrenewal, the end date of the contract 82
period. This subparagraph shall not apply if the health carrier and 83
participating provider agree, in writing, to the termination or 84
nonrenewal of the contract and the health carrier and participating 85
provider provide the notices required under subparagraphs (A) and (B) 86
of this subdivision] until the earlier of the date the dispute is resolved 87
or the policyholder's renewal date. 88
Sec. 6. Subdivision (2) of subsection (a) of section 38a -591c of the 89
general statutes is amended by adding subparagraph (D) as follows 90
(Effective January 1, 2027): 91
(NEW) (D) For each utilization review of a health care service ordered 92
by a provider in the highest tier or level of the health carrier's tiered 93
network, there shall be a rebuttable presumption that such health care 94
service under review is medically necessary if such service was ordered 95
by a provider in the highest tier or level of a health carrier's tiered 96
network acting within such provider's scope of practice. A health 97
carrier, or any utilization review company or designee of a health carrier 98
that performs utilization review on behalf of the health carrier, shall 99
have the burden of proving that a health care service ordered by a 100
provider in the highest tier or level of such health carrier's tiered 101
network is not medically necessary. For purposes of this subparagraph, 102
"tiered network" has the same meaning as provided in section 38a-472f, 103
as amended by this act. 104
Sec. 7. Subsection (c) of section 38a -591e of the general statutes is 105
repealed and the following is substituted in lieu thereof (Effective January 106
1, 2027): 107
(c) (1) (A) When conducting a review of an adverse determination 108
under this section, the health carrier shall ensure that such review is 109
conducted in a manner to ensure the independence and impartiality of 110
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the clinical peer or peers involved in making the review decision. 111
(B) If the adverse determination involves utilization review, the 112
health carrier shall designate an appropriate clinical peer or peers to 113
review such adverse determination. Such clinical peer or peers shall not 114
have been involved in the initial adverse determination. 115
(C) (i) For each review of an adverse determination under this section 116
for a health care service ordered by a provider in the highest tier or level 117
of the health carrier's tiered network, there shall be a rebuttable 118
presumption that each health care service under review is medically 119
necessary if such service was ordered by a provider in the highest tier 120
or level of such health carrier's tiered network acting within such 121
provider's scope of practice. The health carrier may rebut such 122
presumption by reasonably substantiating to the clinical peer or peers 123
conducting the review under this section that such service is not 124
medically necessary. For purposes of this clause, "tiered network" has 125
the same meaning as provided in section 38a -472f, as amended by this 126
act. 127
[(C)] (ii) The clinical peer or peers conducting a review under this 128
section shall take into consideration all comments, documents, records 129
and other information relevant to the covered person's benefit request 130
that is the subject of the adverse determination under review, that are 131
submitted by the covered person or the covered person's authorized 132
representative, regardless of whether such information was submitted 133
or considered in making the initial adverse determination. 134
(D) Prior to issuing a decision, the health carrier shall provide free of 135
charge, by facsimile, electronic means or any other expeditious method 136
available, to the covered person or the covered person's authorized 137
representative, as applicable, any new or additional documents, 138
communications, information and evidence relied upon and any new or 139
additional scientific or clinical rationale used by the health carrier in 140
connection with the grievance. Such documents, communications, 141
information, evidence and rationale shall be provided sufficiently in 142
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advance of the date the health carrier is required to issue a decision to 143
permit the covered person or the covered person's authorized 144
representative, as applicable, a reasonable opportunity to respond prior 145
to such date. 146
(2) If the review under subdivision (1) of this subsection is an 147
expedited review, all necessary information, including the health 148
carrier's decision, shall be transmitted between the health carrier and the 149
covered person or the covered person's authorized representative, as 150
applicable, by telephone, facsimile, electronic means or any other 151
expeditious method available. 152
(3) If the review under subdivision (1) of this subsection is an 153
expedited review of a grievance involving an adverse determination of 154
a concurrent review request, pursuant to 45 CFR 147.136, as amended 155
from time to time, the treatment shall be continued without liability to 156
the covered person until the covered person has been notified of the 157
review decision. 158
Sec. 8. Subsection (a) of section 38a-510 of the 2026 supplement to the 159
general statutes is repealed and the following is substituted in lieu 160
thereof (Effective October 1, 2026): 161
(a) No insurance company, hospital service corporation, medical 162
service corporation, health care center or other entity delivering, issuing 163
for delivery, renewing, amending or continuing an individual health 164
insurance policy or contract that provides coverage for prescription 165
drugs may: 166
(1) Require any person covered under such policy or contract to 167
obtain prescription drugs from a mail order pharmacy as a condition of 168
obtaining benefits for such drugs; or 169
(2) Require, if such insurance company, hospital service corporation, 170
medical service corporation, health care center or other entity uses step 171
therapy for such drugs, the use of step therapy (A) for any prescribed 172
drug for longer than thirty days, (B) for a prescribed drug for cancer 173
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treatment [for an insured who has been diagnosed with stage IV 174
metastatic cancer, multiple sclerosis or rheumatoid arthritis, provided 175
such prescribed drug is in compliance with approved federal Food and 176
Drug Administration indications ] or for the treatment of disabling or 177
life-threatening chronic diseases , or (C) for the treatment of 178
schizophrenia, major depressive disorder or bipolar disorder, as defined 179
in the most recent edition of the American Psychiatric Association's 180
"Diagnostic and Statistical Manual of Mental Disorders". 181
(3) At the expiration of the time period specified in subparagraph (A) 182
of subdivision (2) of this subsection or for a prescribed drug described 183
in subparagraph (B) or (C) of subdivision (2) of this subsection, an 184
insured's treating health care provider may deem such step therapy 185
drug regimen clinically ineffective for the insured, at which time the 186
insurance company, hospital service corporation, medical service 187
corporation, health care center or other entity shall authorize 188
dispensation of and coverage for the drug prescribed by the insured's 189
treating health care provider, provided such drug is a covered drug 190
under such policy or contract. If such provider does not deem such step 191
therapy drug regimen clinically ineffective or has not requested an 192
override pursuant to subdivision (1) of subsection (b) of this section, 193
such drug regimen may be continued. For purposes of this section, "step 194
therapy" means a protocol or program that establishes the specific 195
sequence in which prescription drugs for a specified medical condition 196
are to be prescribed. 197
Sec. 9. Subsection (a) of section 38a-544 of the 2026 supplement to the 198
general statutes is repealed and the following is substituted in lieu 199
thereof (Effective October 1, 2026): 200
(a) No insurance company, hospital service corporation, medical 201
service corporation, health care center or other entity delivering, issuing 202
for delivery, renewing, amending or continuing a group health 203
insurance policy or contract that provides coverage for prescription 204
drugs may: 205
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(1) Require any person covered under such policy or contract to 206
obtain prescription drugs from a mail order pharmacy as a condition of 207
obtaining benefits for such drugs; or 208
(2) Require, if such insurance company, hospital service corporation, 209
medical service corporation, health care center or other entity uses step 210
therapy for such drugs, the use of step therapy (A) for any prescribed 211
drug for longer than thirty days, (B) for a prescribed drug for cancer 212
treatment [for an insured who has been diagnosed with stage IV 213
metastatic cancer, multiple sclerosis or rheumatoid arthritis, provided 214
such prescribed drug is in compliance with approved federal Food and 215
Drug Administration indications ] or for the treatment of disabling or 216
life-threatening chronic diseases , or (C) for the treatment of 217
schizophrenia, major depressive disorder or bipolar disorder, as defined 218
in the most recent edition of the American Psychiatric Association's 219
"Diagnostic and Statistical Manual of Mental Disorders". 220
(3) At the expiration of the time period specified in subparagraph (A) 221
of subdivision (2) of this subsection or for a prescribed drug described 222
in subparagraph (B) or (C) of subdivision (2) of this subsection, an 223
insured's treating health care provider may deem such step therapy 224
drug regimen clinically ineffective for the insured, at which time the 225
insurance company, hospital service corporation, medical service 226
corporation, health care center or other entity shall authorize 227
dispensation of and coverage for the drug prescribed by the insured's 228
treating health care provider, provided such drug is a covered drug 229
under such policy or contract. If such provider does not deem such step 230
therapy drug regimen clinically ineffective or has not requested an 231
override pursuant to subdivision (1) of subsection (b) of this section, 232
such drug regimen may be continued. For purposes of this section, "step 233
therapy" means a protocol or program that establishes the specific 234
sequence in which prescription drugs for a specified medical condition 235
are to be prescribed. 236
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This act shall take effect as follows and shall amend the following
sections:

Section 1 July 1, 2026 New section
Sec. 2 October 1, 2026 38a-477i(a)(2)
Sec. 3 from passage New section
Sec. 4 October 1, 2026 New section
Sec. 5 October 1, 2026 38a-472f(g)(1)(C)
Sec. 6 January 1, 2027 38a-591c(a)(2)(D)
Sec. 7 January 1, 2027 38a-591e(c)
Sec. 8 October 1, 2026 38a-510(a)
Sec. 9 October 1, 2026 38a-544(a)

INS Joint Favorable
APP Joint Favorable
JUD Joint Favorable