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News from State Senate President Pro Tempore Martin Looney

July 15, 2016

Capitol address
Legislative Office Building
Room 3300
Hartford, CT 06106-1591

E-mail me here

On the Web

Capitol: 860-240-0375
Toll-free: 1-800-842-1420

Special Report on Important Health Care Laws

Senator Looney on health careWelcome to this first in a series on health care issues. Let's begin with a review of last year's health care reform bill.

Protecting patients in our health care system has always been a major priority for me. Last year, PA 15-146 made significant reforms to the system including protecting patients from certain facility fees and creating a transparency website where patients can view costs for common medical procedures as well as creating a health information exchange that will give patients direct access to their medical records. Some of the provisions of that legislation will roll out over time, while others are already in effect.

Because of this act, as of January 2017, hospitals will no longer be able to charge facility fees for evaluation and management services at outpatient clinics. Facility fees for other services will still be allowed (for now), but they are required to be more transparent. Facility fees are extra costs tacked on to medical procedures and services at a hospital owned facility. These additional charges are often surprising and burdensome when a physician's practice is purchased by a hospital and prices increase unexpectedly as a result of the added fee. Patients will now be notified when a practice is bought by a hospital and facility fees may be imposed so there should be no more surprises. For uninsured patients, the facility fee charged is capped at the Medicare rate. Hospitals are also now required to report to the state detailed information on the facility fees that they charge. This information will provide a basis for further regulating these fees.

The Health Insurance Exchange will soon have a website to give consumers cost and other quality information regarding common medical procedures. Under this law, patients also have the right to request (and hospitals are required to provide) the cost of any upcoming procedure for that patient.

The Health Information Exchange (which is different than the Health Insurance Exchange) created by this act will give patients access to their entire medical record and give patients control over which providers can also view the record. If a hospital does not submit its records to the information exchange, it will be committing an unfair trade practice.

Effective July 2016, for emergency services, an insured patient will never have to pay more than the in-network rate regardless of the network status of the provider. These out of network providers will also be able to bill the insurer directly so the experience for patients receiving emergency services will be the same regardless of whether the provider is in or out of network.

Patients will also be protected from surprise billing; if they are not notified that a physician who sees the patient at an in-network hospital is out of network, the patient can only be billed at the in-network rate.

While the patient experience for emergency services must be the same as if the provider was in network, there is a slightly different reimbursement method between the insurer and the provider. The reimbursement must be the greater of the in-network rate, the Medicare rate, or the "usual customary and reasonable rate" (UCR).

Just last week, the Department of Insurance designated FAIR Health Inc. as the official benchmarking database for determining UCR reimbursement for emergency services received out of network. This selection complies with the legislation's requirement that the benchmark be set according to an independent nonprofit's database that is not associated with any insurer.

The act also required that the Governor's Health Care Cabinet conduct a thorough study on cost containment. The Cabinet has selected a vendor to perform this study and it is examining how other states are approaching this issue. A report with recommendations is due to the General Assembly before the next legislative session.

In addition, the legislation increases oversight of hospital consolidations. It seeks to increase competition in the health care market by requiring that large hospital mergers and acquisitions be subject to appropriate market review in terms of costs and market power. The bill requires a cost and market impact study for large consolidations, to ensure that the cost and quality improvements that are often claimed as the reason for these mergers actually come to pass. This bill has numerous other provisions; please feel free to contact me for any additional information.

In a separate measure last year, the General Assembly required health insurers to cover off-label use of drugs for many conditions if there is evidence in medical literature showing that the drug is effective for the patient's condition. This requirement will allow physicians to treat patients using their medical judgment without interference from the insurers. If you have a prescription for an off-label use of a prescription drug denied by your insurer, be sure to call the insurer's attention to statute sections 38a-492b and 38a-518b as amended in 2015 which now require this coverage.


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My mailing address is:
Senator Martin Looney, Legislative Office Building, Room 3300, Hartford, Connecticut 06106
Capitol telephone: 860-240-0375, or Toll-free: 1-800-842-1420

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