General Assembly Raised Bill No. 342 seeks to improve health coverage regulations in Connecticut, with an effective date of July 1, 2026. The bill requires all insurers and health care entities to include provisions in their contracts with health care providers that ensure equal reimbursement rates for covered outpatient benefits based on geographic regions, regardless of the provider's employer or affiliation. It also mandates a statement confirming compliance with these reimbursement standards and prohibits health carriers from automatically downcoding claims without a clinical peer review. Additionally, the bill establishes a rebuttable presumption of medical necessity for services ordered by providers in the highest tier of a health carrier's network, shifting the burden of proof to the health carrier. Other amendments include extending contract terms post-termination until disputes are resolved and requiring the Insurance Commissioner to study various insurance statutes, with a report due by January 1, 2027.

The bill further amends existing laws related to health insurance policies, particularly concerning adverse determinations and step therapy for prescription drugs. It mandates that health carriers designate clinical peers who were not involved in the initial adverse determination to review such cases and requires them to provide new evidence or rationale to the covered person before issuing a decision on the review. The bill also prohibits insurance companies from requiring individuals to obtain prescription drugs solely from mail order pharmacies and limits step therapy protocols to a maximum of thirty days. It expands the conditions under which step therapy cannot be mandated, including for disabling or life-threatening chronic diseases and certain mental health disorders, and allows treating health care providers to deem step therapy regimens clinically ineffective, facilitating coverage for alternative prescribed drugs. The effective dates for these provisions vary, with some set for October 1, 2026, and others for January 1, 2027.