Senate Democrats Announce Two Priority Bills for Patient Protections & Rx Affordability
HARTFORD – Senate Democrats today unveiled two more priority bills for the 2025 legislative session: Senate Bills 10 and 11, concepts which seek to enhance health insurance patient protections and prescription drug affordability.
Senate President Pro Tem Martin Looney (D-New Haven), Senate Majority Leader Bob Duff (D-Norwalk), and Senators Jorge Cabrera (D-Hamden) and Matt Lesser (D-Middletown) said the two bills are among the Top 12 legislative goals for Senate Democrats this session, which ends at midnight on Wednesday, June 4.
“Onerous insurance company burdens and the ever-increasing cost of prescription drugs are a constant thorn in the side of consumers, and we must do our utmost in the General Assembly to contain these where we can,” said Sen. Looney.
“We know that only about one percent of people who are denied a claim or prior authorization will ever fight that denial – but when they do, they’ll win about 75% of the time. That tells me there’s a lot of room for improvement in the way that health insurance and the people it insures is managed in this state,” said Sen. Duff. “Hundreds of thousands of people are covered by insurance in Connecticut, and insurance companies employ about 60,000 people in the state. It’s a big business with a direct, personal impact on most everyone.”
“With each passing day, people have a better understanding of the life-changing effects that insurance company decisions can have on them and their families. Connecticut has a responsibility to step in where it can and level the playing field when it comes to these patient/insurance company relationships,” said Sen. Cabrera, who is Senate Chair of the Insurance and Real Estate Committee.
“Prescription drug costs are absolutely unsustainable and there is a strong, bipartisan coalition ready to tackle this incredibly complex issue,” said Sen. Matt Lesser, Chair of the Human Services Committee. “This is tough but important work and it is essential that we center the voices of perspectives of Connecticut patients. I am grateful to Senators Looney and Duff for making this a priority piece of legislation and I am eager to work together with my colleages to deliver real, tangible relief for Connecticut residents.”
Senate Bill 10: An Act Concerning Heath Insurance and Patient Protection
Senate Bill 10, “An Act Concerning Heath Insurance and Patient Protection,” will include several components, including:
Mental Health Parity Enforcement
In July 2019, Connecticut passed a mental health parity law which received unanimous and bipartisan support. But the actual enforcement of that law has been slow, leaving some residents with coverage denials and inadequate care. A recent Office of Health Strategy report found that four of seven major commercial insurance providers in Connecticut are meeting federal warning signs for parity noncompliance, highlighting the urgent need for stronger enforcement. SB 10 would establish a penalty for any health carrier in Connecticut that doesn’t comply with the legal requirements for mental health and substance use disorder benefit parity.
A Prohibition on Automatic ‘Downcoding’
Downcoding is when an insurance company decides to pay for a lower level of care than what a doctor ordered or provided. The end result is that doctors are paid less than the cost of their service, and over time may be forced to suggest a less-effective procedure to ensure that the care is covered. Automatic downcoding is when the downcode decision is made by an insurance company’s algorithm or artificial intelligence, as opposed to review by physicians in the same speciality, which is Connecticut state law when it comes to denial of claims. SB 10 would extend mandatory human review to downcoding decisions.
Further Restrictions on an Insurance Company’s Ability to Implement Less-Expensive “Step Therapies”
Step Therapy, sometimes called a ‘fail first’ policy, is when an insurance company requires doctors and patients to try less-expensive, less-effective medical procedures or drugs to address a medical issue before moving on to the next “step” in treatment. This is a particularly problematic insurance policy when it comes to degenerative chronic diseases for which patients can suffer irreversible disability during the time they are denied the proper treatment. A state law passed in 2014 (Public Act 14-118) bars certain health insurers that use prescription drug step therapy regimens from requiring their use for more than 60 days. That law has since been updated, reducing the 60 days to 30 and prohibiting step therapy until January 1, 2027 for drugs used to treat schizophrenia, major depressive disorder, or bipolar disorder. SB10 will further restrict an insurance company’s attempt to use step therapy.
Senate Bill 11: An Act Concerning Prescription Drug Access and Affordability
Residents across Connecticut and the nation are struggling under the unaffordable cost of prescription drug prices. Senator Lesser chairs the bipartisan, bicameral Prescription Drug Task Force which brings together a broad coalition of legislators, doctors, nurses, pharmacists, experts from the pharmaceutical industry, advocates and patients to determine a legislative solution to protecting and expanding patient care. Senate Bill 11 will include recommendations from the bipartisan task force.
According to a 2022 study of more than 1,300 Connecticut adults from the Healthcare Value Hub found that:
-Over half (55%) experienced at least one healthcare affordability burden in the past year;
-Nearly 4 in 5 (78%) worry about affording healthcare in the future;
-Over 1 in 4 (28%) of those surveyed with household incomes under $50,000 had rationed medication in the last 12 months due to cost.
-Lower-income respondents and respondents with disabilities are more likely to go without care and incur debt due to healthcare costs; and
-Across party lines, respondents express strong support for government-led solutions.
Connecticut Democrats have worked to address various barriers in access to prescription drugs, including capping the out-of-pocket cost of insulin at $25, allowing pharmacists to prescribe birth control, and authorizing the ArrayRx discount drug program, Senate Bill 11 will build upon this work through a number of initiatives:
Address Pharmacy Benefit Managers (PBMs)
PBMs administer prescriptions or services of a health benefit plan on the behalf of plan sponsors. These third party middle men drive up costs for insurers, pharmacies, and ultimately patients. In Connecticut, three PBMs make up 64% of the market and the top 5 cover 95% of residents.
Senate Bill 11 seeks to establish a fiduciary responsibility of PBMs to ensure they pass along any savings to their plan sponsors.
Bulk Purchasing
Pooling state agencies to increase buying power to bring down the cost of prescription drugs.
Increasing Nursing Home Investment into Patient Care
SB11 seeks to increase quality of care in Connecticut nursing homes by requiring care providers reinvest 80% of their revenue back into patient care.
Expand Emergency Medicaid Coverage
Currently, Connecticut state statute has a narrow definition of “emergency services” as it relates to Medicaid coverage and SB 11 seeks to expand the definition to include a greater range of outpatient coverage. Expanding coverage for certain emergency services will bridge gaps in healthcare access and address disparities in health outcomes.
Senate Bill 11 will also require that any changes to the Medicaid care and delivery model must go be approved by the legislature.
