Insurance and Real Estate Committee
JOINT FAVORABLE REPORT
Bill No.: SB-1045
AN ACT CONCERNING STEP THERAPY, ADVERSE DETERMINATION AND
UTILIZATION REVIEWS, AND HEALTH INSURANCE COVERAGE FOR
Title: CHILDREN, STEPCHILDREN AND OTHER DEPENDENT CHILDREN.
Vote Date: 3/22/2021
Vote Action: Joint Favorable
PH Date: 3/18/2021
File No.:
Disclaimer: The following JOINT FAVORABLE Report is prepared for the benefit of the
members of the General Assembly, solely for purposes of information, summarization and
explanation and does not represent the intent of the General Assembly or either chamber
thereof for any purpose.
SPONSORS OF BILL:
Insurance and Real Estate Committee
REASONS FOR BILL:
The bill aims to increase patient and medical provider control over treatment options that they
deem appropriate and in the best interest of the patient. Before SB 1045, health insurers
could deny coverage if they believed it was not medically necessary, leaving the patient with
the burden to prove otherwise. The bill addresses this issue by flipping the burden of proof to
the insurers, who would now have to prove that the treatment was not medically necessary.
SB 1045 further expands a patients ability to get appropriate medical treatment by prohibiting
certain health carriers from requiring the use of step therapy for drugs prescribed to treat
behavioral health conditions or chronic, disabling or life-threatening conditions or diseases.
The bill also seeks to improve the accuracy of third-party decisions to whether a treatment is
medically necessary by increasing the certification requirement of clinical peers and allowing
them the authority reverse adverse determinations. Lastly, SB 1045 extends how long a child,
stepchild, or dependent child can remain under their parents insurance to the one-year
anniversary date after turning twenty-six.
RESPONSE FROM ADMINISTRATION/AGENCY:
Ted Doolittle, Healthcare Advocate, Office of Healthcare Advocate: Supports SB 1045
but has concerns that insurance companies will be deprived of certain tools designed to
restrain excessive spending on overpriced brand names. They fear this could exacerbate the
cost of healthcare outpacing the ability to pay. The OHA recommends the CGA implement a
more targeted approach that eliminates step therapy only for those conditions where the
negative impacts clearly outweigh the economic benefits.
NATURE AND SOURCES OF SUPPORT:
Connecticut Hospital Association: Sections 6 and 7 of SB 1045 will help temper the
overuse of utilization management processes by putting healthcare decisions back in the
hands of patients and providers rather than health insurance companies.
Connecticut Psychiatric Society: Support SB 1045 limiting the utilization of step-therapy
because they believe it is not fair and harmful to patients. They also support making the
people who determine if the care was medically necessary as qualified as the doctors who
are rendering the care. Lastly, they support the amendment that flips the burden to the
insurer to demonstrate how the care is not medically necessary. They believe SB 1045 will
allow physicians to provide better care to their patients.
Connecticut State Medical Society: Health insurers administrative hurdles commonly
delay access to care for patients and serve as impositions into the patient-physician
relationship and decision-making process. CSMS is strongly supportive of these amendments
that would severely limit the circumstances in which health insurers can utilize step therapy.
Supports the revises to the definition of a clinical peer, however, they recommend further
changes to require a clinical peer to hold a license in Connecticut and to have a doctorate or
medical degree. Overall, SB 1045 provides changes to the Connecticut General Statues that
will help physicians provide better care to their patients.
Hartford Health Care: Supports SB 1045 because it, among other things, would limit the
use of step therapy; flip the burden of proving medical necessity from the provider to the
insurance plan, so that services would be presumed medically necessary unless a carrier
proves otherwise; and makes changes to the definition and role of a clinical peer in adverse
determinations and utilization review.
Kathleen Flaherty, Executive Director, Connecticut Legal Rights Project: Step therapy
and prior authorizations make it difficult for people who are trying to manage chronic illnesses
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and behavioral health conditions effectively to do so quickly. These policies hurt people, and
SB 1045 is an important bill that will address these issues and increase access to health
care.
Martin M. Looney, Senator, Connecticut General Assembly: SB 1045 would provide a
number of innovative protections for patients. He supports switching the burden of proof to
the insurers because they possess the relevant information and would not be as able to
interfere with medical decisions they are not qualified to make. He believes the bill will also
strengthen patient protections against the insurers use of step therapy, which has prevented
patients from receiving appropriate treatment from their healthcare provider. He supports the
refined definition of clinical peer in the appeal process for adverse determinations because
it will lead to more accurate and appropriate determinations that will benefit all parties. Sen.
Looney also believes SB 1045 allowing children to remain on their parents health insurance
through the end of the year after turning twenty-six levels the playing field to what is already
done by a lot of insurers.
Michelle Carpino Cook, Representative, Connecticut General Assembly: Individuals
with serious behavioral health needs have complex medical histories and should not be met
with counterintuitive hurdles when trying to access the appropriate medication. She supports
SB 1045 because it prevents insurance companies from requiring a prior authorization or
step-up mandate that can cause detrimental health consequences.
Ted Doolittle, Healthcare Advocate, Office of Healthcare Advocate: Supports SB 1045
but has concerns that insurance companies will be deprived of certain tools designed to
restrain excessive spending on overpriced brand names. They fear this could exacerbate the
cost of healthcare outpacing the ability to pay. The OHA recommends the CGA implement a
more targeted approach that eliminates step therapy only for those conditions where the
negative impacts clearly outweigh the economic benefits.
The Connecticut Society of Eye Physicians: Supports SB 1045 because it will improve
access to prescription medications that are in the best interest of the patient. It will allow
physicians to make medical decisions that improve the quality of life for these individuals and
help achieve optimal outcomes.
Page 3 of 4 SB-1045
Thomas Burr, Community and Affiliates Relations Manager, National Alliance on
Mental Illness Connecticut: Providers must be able to select from a full range of drug
options to maximize treatment efficacy, minimize side effects, and avoid drug-to-drug
interactions. Studies show a connection to more emergency visits and higher rates of suicidal
behavior and homelessness for patients who report difficulties accessing their needed
medication. He believes step therapy is harmful to patients for the mentioned reasons and
does not result in any net savings to either the State of Connecticut or any health insurance
provider.
NATURE AND SOURCES OF OPPOSITION:
Connecticut Association of Health Plans: The prohibition of step therapy in section 2 negates
a critical tool that carriers use to support evidenced based treatment and to control costs. Section 3
changes the definition of a clinical peer that makes prior authorization, which is used as a way to make
sure care is appropriate and costs are in check, almost impossible to utilize. Section 4 flips the burden
of proof upside down and will jeopardize what was previously a fair process surrounding medical
necessity decisions. Medical necessity determinations are a critical check and balance on the current
system to make sure that care provided is appropriate. The new process established under SB 1045 is
enormously cumbersome and virtually unworkable and if enacted, would represent the single most
expensive mandate ever passed.
Sam Hallemeier, Director of State Affairs, Pharmaceutical Care Management
Association: Concerned that SB 1045 will restrict their ability to provide a high-quality
benefit and put downward pressure on the rising cost of prescription drugs. Step therapy is a
tool designed to ensure that patients receive clinically appropriate and cost-effective drug
therapies. If the bill goes into effect the projected drug cost for fully insured employers and
commercial health plans would increase by $544 million in the state over the next ten years.
It would also negatively impact employers and health plans that now cover some 700,000
beneficiaries in Connecticut. SB 1045 will increase the cost of providing reliable and
affordable access to prescription drugs.
Reported by: Kyle Del Balso Date: April 5,2021
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Statutes affected:
Raised Bill:
INS Joint Favorable:
File No. 370:
APP Joint Favorable: