Yesterday, Connecticut Governor Ned Lamont signed into law HB6669, “An Act Protecting Patients and Prohibiting Unnecessary Health Care Costs” (the “Act”), which seeks to reduce the costs of health care services for Connecticut residents. The law is wide-ranging and aims to increase competition in the healthcare market, increase pricing transparency, and reduce prescription drug costs. We have summarized the main provisions of the law below.
Requirements for contracting with the paying provider (As of July 1, 2024)
The law prohibits health care providers, carriers, plan administrators, and any entities contracting on their behalf from offering, soliciting, asking, renewing, or entering into health care contracts that directly or indirectly include ‘all or nothing’ clauses and anti-directive clauses. , or anti-class clauses, or gag clauses. By law, any such provision in a health care contract, written policy, written procedure, or agreement entered into, renewed, or modified on or after July 1, 2024 is null and void.
In addition, the law requires that all contracts involving tiered networks include a clause requiring that the health carrier submit to the participating provider, upon request, the participating provider’s calculated score and related data, as available, and a description of the criteria used in selecting and ranking participating providers. . By law, this must include:
- definitions and specifications of procedures related to factors such as cost, quality, efficiency and satisfaction used to develop standards and measure performance;
- a specified period of time of at least one year for performance measurement; And
- Summary of the grievance process in place for participating service providers to appeal the results of rating decisions and performance measures.
PBM Practices and Contracts (As of October 1, 2023)
On and after January 1, 2024, contracts between Pharmacy Benefit Managers (PBMs) and 340B Covered Entities must not contain any of the following:
- The rate paid for a prescription drug is lower than the rate paid to non-340B pharmacies;
- a fee or modification that is not charged to non-340B providers or pharmacies;
- a fee or adjustment that exceeds the fee or adjustment amount charged to providers or pharmacies other than 340B;
- Any provision that prevents or interferes with a patient’s choice to receive medication from a 340B-covered entity; or
- Any provision that excludes a Covered 340B Entity from the PBM Network based on participation in the 340B Program.
In addition, PBMs will not be allowed to consider whether the entity is a 340B covered entity when determining reimbursement rates.
By January 1, 2025, the Office of Health Strategy will be required to report its analysis of PBMs’ prescription drug distribution practices, including, but not limited to, spread pricing arrangements, manufacturer discounts, transparency, fees charged, and financial incentives to add. Medications to health plan formulations and an evaluation of prescription drug distribution practices conducted by PBMs in other states. This report will make recommendations to reduce the costs of prescription drugs and regulate results-based management.
Medication discount card program (As of October 1, 2023)
The law mandates the drug discount card program to be made available to all Connecticut residents. The Act directs the comptroller to pool the purchasing power of prescription drugs to lower drug costs, negotiate discounts with manufacturers, centralize drug purchases, and establish volume reduction contracting. It also requires the comptroller to study the feasibility of centralizing contracts at the state level to standardize drug procurement by state agencies, state hospitals, state-run mental health authorities, and other public entities.
Registration in Pharmaceutical Marketing (As of October 1, 2023)
The law requires pharmaceutical manufacturers that employ individuals to perform the duties of drug sales representatives to register annually as a drug marketing company in the form and manner prescribed by the Consumer Protection Commissioner. The Consumer Protection Administration will publish updated lists on its website for all individuals serving as drug sales representatives. Each company annually provides the delegate with information including: the number of contacts each salesperson has had with practitioners and pharmacists; The specialty of each practitioner and pharmacist; whether samples, materials or gifts of any value have been given to a practitioner or pharmacist or their employees; And reports on all the free samples. Sales representatives will also be required to disclose a list price of a legendary drug when the representative provides information about the drug based on the dose and quantity as indicated on the medication package insert, and information about the effectiveness of a variation of the legendary drug marketed to various ethnicities. and ethnic groups if such information is available. The law provides enforcement discretion to the commissioner if the company fails to comply with any of these requirements.
Reducing prescription drug costs (As of October 1, 2023)
The law updated the process for listing drugs that are too expensive for the state. The Office of Health Strategy (“OHS”) will still be required to compile a list of 10 outpatient prescription drugs that have been determined to be provided at significant cost to the state, given net cost, or critical to public health. This will include drugs from different outpatient treatment classes and at least one generic drug. Medicines will be included only if the cost of bulk purchase, less any rebates paid to the state, increased 1) by at least 16% during the two immediately preceding calendar years; and 2) not be less than $40 for a course of treatment.
The preliminary list will be available for public comment for at least 30 days during which time the manufacturer will be allowed to submit documentation to prove that costs have not exceeded the above limits. If created, the drug will be removed from the list before publishing.
Facility fees (As of July 1, 2023)
If a hospital or health system charges a facility fee using the Current Procedural Terms Evaluation and Management Code (CPT 300 E/M) or the Evaluation and Management Code (CPT A/M) for outpatient services provided at a hospital-based facility, the hospital health system will be required to provide the patient with a notice In writing that includes the following information: 1) that the facility is part of a hospital or health system and that it charges additional fees to the professional and is separate from the fees charged by the provider; 2) the amount of the patient’s potential financial responsibility including facilities and professional fees, a statement that the patient’s actual financial responsibility will depend on the services provided to the patient, an explanation that the patient may have a greater financial responsibility than if the services were not provided by the hospital-based facility, and a telephone number The patient may contact him for additional information and estimates; 3) that patients should contact their health insurance company for additional information about potential financial liability for fees and charges.
The law requires that each billing statement that includes a facility fee clearly identify the facility fee as such, provide the corresponding Medicare facility fee reimbursement rate for the same service as a comparison, and include a statement that the fee is intended to cover the provider’s operating expenses, inform the patient that the patient’s financial responsibility may be less If services are provided in a facility not owned or operated by the hospital or health system, and include written notice of the patient’s right to request a fee reduction. Facilities must inform patients of the facility fee when scheduling services. All of this information must be communicated in plain language, and any written notices required must be accessible and visible to patients.
Finally, this section provides that on and after July 1, 2024, hospitals and health systems will be prohibited from charging facility fees for outpatient health care services that use the CPT code E/M or A/M and are provided on a hospital campus. This will not apply to the following services: wound care, orthopedics, anticoagulants, oncology, obstetrics and solid organ transplants. If these charges are collected after July 1, 2024, OHS will have the discretion to impose civil penalties of up to $1,000 per violation.
Laws certificate needed (As of October 1, 2023)
The law makes it clear that a Certificate of Need (“CON”) will be required for replacement scanners if the applicant is already providing similar imaging services for each of the scanner modalities or functions to be used. However, CONs will not be required to replace non-hospital-based linear scanners or accelerators if they are replacing items previously obtained through CONs.
In addition, the law imposes certain notice requirements on applicants. Applicants should post a notice that applications are being made in local newspapers, on the applicant’s website, at two locations within the affected community, on the local Department of Health website, and on the Occupational Health and Safety website. It also provides OSH greater discretion to implement these policies.
The law is one of several pieces of legislation signed into law by Governor Lamont that aim to protect health care and make it more equitable for Connecticut residents. Other programs include SB956, which sets requirements for discharge criteria regarding follow-up appointments and medications prescribed to patients who are discharged from a hospital or nursing home. Another is SB0003 which defines standards for consumer health data access and sharing. Connecticut providers should review these updates carefully to ensure continued compliance.
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