Connecticut Expands OHS Authority | Robinson+Cole Health Law Diagnosis


As previously written, Connecticut Governor Ned Lamont recently signed into law the state budget as Public Law 22-118 (Law), which made various amendments to the Connecticut statutes. Among the changes, the law expands the authority of Connecticut’s Office of Health Strategy (OHS).

The law requires ESS to develop and adopt annual targets for growth in health care costs and primary care expenditures. OHS is required to publish benchmarks and spending targets on its website by July 1, 2022. Cost growth benchmarks and spending targets in primary care are to be published as a percentage of total medical spending for years 2021 to 2025. expenses” is defined in law and includes the total cost of care for a patient population of a provider entity (described below) or a payer calculated by totaling claims-based expenses , non-claims payments (such as incentive and care coordination payments), and patient cost-sharing amounts. A Provider Entity is “an organized group of clinicians who (1) come together for contractual purposes or (2) are an established billing unit with enough assigned lives (i.e. patients), collectively, to participate in the total cost of care contracts during any given calendar year, even if it does not participate in these contracts. The term “total cost of care contract” is not defined. At a minimum, a provider entity should include primary care providers. Quality benchmarks are to be published for the years 2022 through 2025. Thereafter, OHS is to develop and adopt the aforementioned benchmarks and spending targets for all subsequent five years. The law includes a process for public participation and legislative approval of benchmarks.

As of August 15, 2022, the law requires each payer to report the necessary data to the OHS for it to calculate “total health care expenditure”, as well as primary care expenditure as a percentage of total medical expenditure and the “net cost of private health care”. Insurance.” Under the law, total health care expenditure means the sum of all health care expenditures in Connecticut from public and private sources during a single year. The net cost of private health insurance is defined under the Act as “the difference between premiums earned and benefits incurred, including the cost of paying bills to insurers; advertising; sales commissions and other administrative costs; net additions or subtractions from reserves; credit and dividend rates; premium taxes; and profits or losses.

By August 15, 2023, Provider Entities and Payers shall report annually to OHS on the Health Care Quality Criteria adopted by OHS for that particular year and prior years, if OHS the request.

In addition, OHS must publish an annual report on total health care expenditures beginning March 31, 2023. The report must break down overall medical expenditures by payers and providers and include information on service category trends, primary care expenses, insurance costs by type of policy. , and any information relating to inflation, access to care and emergency response.

The law gives the OHS the authority to identify provider entities that exceed cost growth and quality criteria or fail to meet the primary care spending target. Prior to identifying provider entities that are not meeting cost and quality growth criteria or failing to meet primary care spending targets, OHS should meet with provider entities at their request to review and validate data collected.

Notably, the law also allows OHS to require provider entities identified as contributing significantly to exceeding the above benchmarks to participate in a public hearing to discuss ways to reduce their contribution to rising health care costs. health.

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