CHAPTER 700c

HEALTH INSURANCE

Table of Contents

Sec. 38a-469. Definitions.

Sec. 38a-470. (Formerly Sec. 38-174n). Lien on workers’ compensation awards for insurers. Notice of lien.

Sec. 38a-471. (Formerly Sec. 38-174o). Third party prescription programs. Notice of cancellation. Applicability of section.

Sec. 38a-472. (Formerly Sec. 38-174a). Assignment of insurance proceeds to doctor, hospital or state agency. Lien for state care. Notice of lien.

Sec. 38a-472a. Medical provider indemnification agreements prohibited.

Sec. 38a-472b. Medical provider indemnification contracts. Professional actions and related liability.

Sec. 38a-472c. Dental policies. Estimate of reimbursement.

Sec. 38a-472d. Public education outreach program re health insurance availability and eligibility requirements.

Sec. 38a-472e. Health insurer. Requirements re offer to contract with a school-based health center.

Sec. 38a-472f. Provider network adequacy.

Sec. 38a-472g. Restrictions applicable to preauthorization or precertification.

Sec. 38a-472h. Dental fees for noncovered benefits. Posting required by dentists. Exceptions.

Sec. 38a-472i. Payment amount of professional services component of covered colonoscopy or endoscopic services.

Sec. 38a-473. Medicare supplement expense factors. Age, gender, previous claim or medical history rating prohibited.

Sec. 38a-474. Medicare supplement policy rate increases: Procedure. Age, gender, previous claim or medical history rating prohibited.

Sec. 38a-475. Precertification of long-term care policies under the Connecticut Partnership for Long-Term Care. Regulations.

Sec. 38a-476. Preexisting condition coverage.

Sec. 38a-476a. Compliance with the Health Insurance Portability and Accountability Act. Guaranteed renewability. Discrimination based on health status, newborns’ and mothers’ health prohibited. Parity of mental health benefits. Disclosure of information for employers. Construction. Application. Regulations.

Sec. 38a-476b. Standards re psychotropic drug availability in health plans.

Sec. 38a-476c. Policies and contracts with variable network and enrollee cost-sharing. Approval. Limitations.

Sec. 38a-477. Standardized claim forms. Information necessary for filing a claim. Regulations.

Sec. 38a-477a. Notification by Insurance Commissioner of required benefits and policy forms.

Sec. 38a-477b. Postclaims underwriting prohibited unless approval granted. Application for approval of rescission, cancellation or limitation. Decision. Appeals. Regulations.

Sec. 38a-477c. Disclosure of state and federal medical loss ratio with each health insurance application.

Sec. 38a-478. Definitions.

Sec. 38a-478a. Commissioner’s report to the Governor and the General Assembly.

Sec. 38a-478b. Penalty for managed care organization’s failure to file data and reports. Commissioner’s report to the Governor and the General Assembly on organizations that fail to file data and reports.

Sec. 38a-478c. Managed care organization’s report to the commissioner: Data, reports and information required.

Sec. 38a-478d. List of providers required. Notification to enrollee of termination or withdrawal of enrollee’s primary care provider.

Sec. 38a-478e. Medical protocols. Procedure prior to change. Physician input. Notification of change.

Sec. 38a-478f. Provider profile development requirements.

Sec. 38a-478g. Managed care contract requirements. Plan description requirements.

Sec. 38a-478h. Removal of providers. Notice requirements. Retaliatory action prohibited.

Sec. 38a-478i. Limitation on enrollee rights prohibited.

Sec. 38a-478j. Coinsurance payments based on negotiated discounts.

Sec. 38a-478k. Gag clauses prohibited.

Sec. 38a-478l. Consumer report card required. Content.

Secs. 38a-478m and 38a-478n. Internal grievance procedure; notice re procedure and final resolution; penalties; fines allocated to Office of the Healthcare Advocate. Exhaustion of internal appeal mechanisms; external appeal to commissioner; applicability to health insurers, managed care organizations and utilization review companies; fees; preliminary review; full review; public outreach program; expedited external appeal; requirements for and approval of independent review entities; filing of report.

Sec. 38a-478o. Confidentiality and antidiscrimination procedures required.

Sec. 38a-478p. Expedited utilization review. Standardized process required.

Sec. 38a-478q. Use of laboratories covered by plan required.

Sec. 38a-478r. Emergency rooms. Prudent layperson standard. Presenting symptoms or final diagnosis as basis for coverage.

Sec. 38a-478s. Nonapplicability to self-insured employee welfare benefit plans and workers’ compensation plans.

Sec. 38a-478t. Commissioner of Public Health to receive data.

Sec. 38a-478u. Regulations.

Sec. 38a-478v. Applicability of Unfair and Prohibited Insurance Practices Act. Examination by Insurance Commissioner. Regulations.

Sec. 38a-479. Definitions. Access to fee schedules. Fee information to be confidential.

Sec. 38a-479a. Physicians and managed care organizations to discuss issues relative to contracting between such parties.

Sec. 38a-479b. Material changes to fee schedules. Return of payment by provider. Appeals. Filing of claim by provider under other applicable insurance coverage. Certain clauses, covenants and agreements prohibited. Exception.

Secs. 38a-479c to 38a-479z. Reserved

Sec. 38a-479aa. Preferred provider networks. Definitions. Licensing. Fees. Requirements. Exception, regulations.

Sec. 38a-479bb. Requirements for managed care organizations that contract with preferred provider networks. Requirements for preferred provider networks.

Sec. 38a-479cc. Duties of a preferred provider network when providing services pursuant to a contract with a managed care organization.

Sec. 38a-479dd. Preferred provider network examination of outstanding amounts. Notice. Commissioner’s duties.

Sec. 38a-479ee. Violations. Penalties. Investigations and staffing. Grievances. Referrals from Healthcare Advocate.

Sec. 38a-479ff. Adverse action or threat of adverse action against complainant prohibited. Exception. Civil actions by aggrieved persons.

Sec. 38a-479gg. Regulations.

Secs. 38a-479hh to 38a-479pp. Reserved

Sec. 38a-479qq. Medical discount plans: Definitions, prohibited sales practices, penalties.

Sec. 38a-479rr. Medical discount plan organizations: Licensure. List of authorized marketers. Provider agreements. Minimum net worth. Suspension of authority and revocation or nonrenewal of license. Reinstatement of license. Maintenance of information. Regulations. Penalties. Advertising and marketing materials. Investigations.

Secs. 38a-479ss to 38a-479zz. Reserved

Sec. 38a-479aaa. Pharmacy benefits managers. Definitions.

Sec. 38a-479bbb. Registration of pharmacy benefits managers required. Application for registration. Fee. Surety bond. Exemption from registration.

Sec. 38a-479ccc. Certificate of registration; when issued or refused. Suspension, revocation or refusal to issue or renew registration; grounds.

Sec. 38a-479ddd. Hearing on denial of certificate. Subsequent application.

Sec. 38a-479eee. Investigations and hearings. Powers of commissioner.

Sec. 38a-479fff. Expiration of certificates of registration. Renewal. Fees.

Sec. 38a-479ggg. Regulations.

Sec. 38a-479hhh. Appeals.

Sec. 38a-480. (Formerly Sec. 38-174). Nonapplication to certain policies or contracts.

Sec. 38a-481. (Formerly Sec. 38-165). Approval of individual health application, policy form and rates. Medicare supplement policies and certificates: Age, gender, previous claim or medical history rating prohibited. Loss ratios. Regulations. Certain refunds to be donated to The University of Connecticut Health Center. Underwriting classifications, claim experience and health status. Exceptions. Use of certain prescription drug history prohibited.

Sec. 38a-482. (Formerly Sec. 38-166). Form of policy.

Sec. 38a-482a. Individual health insurance policy to contain definition of “medically necessary” or “medical necessity”.

Sec. 38a-482b. Individual health insurance policy providing limited coverage to include disclosure. Limited coverage defined.

Sec. 38a-482c. Lifetime limit.

Sec. 38a-483. (Formerly Sec. 38-167). Standard provisions of individual health policy.

Sec. 38a-483a. Exclusionary riders for individual health insurance policies. Regulations.

Sec. 38a-483b. Time limits for coverage determinations. Notice requirements.

Sec. 38a-483c. Coverage and notice re experimental treatments. Appeals.

Sec. 38a-484. (Formerly Sec. 38-168). Policy provisions not to be less favorable than standard. Validity of policy issued in violation of law.

Sec. 38a-485. (Formerly Sec. 38-169). Copy of application to be part of new policy or to be furnished with renewal. Alteration of application.

Sec. 38a-486. (Formerly Sec. 38-170). Certain acts not to operate as waiver of rights.

Sec. 38a-487. (Formerly Sec. 38-171). Coverage after termination date of policy.

Sec. 38a-488. (Formerly Sec. 38-172). Discrimination.

Sec. 38a-488a. Mandatory coverage for the diagnosis and treatment of mental or nervous conditions. Exceptions. Benefits payable re type of provider or facility. State’s claim against proceeds.

Sec. 38a-488b. Coverage for autism spectrum disorder therapies.

Sec. 38a-489. (Formerly Sec. 38-174e). Continuation of coverage of mentally or physically handicapped children.

Sec. 38a-490. (Formerly Sec. 38-174g). Coverage for newly born children. Notification to insurer.

Sec. 38a-490a. Coverage for birth-to-three program.

Sec. 38a-490b. Coverage for hearing aids for children twelve and under.

Sec. 38a-490c. Coverage for craniofacial disorders.

Sec. 38a-490d. Mandatory coverage for blood lead screening and risk assessment.

Sec. 38a-491. (Formerly Sec. 38-174h). Coverage for services performed by dentists in certain instances.

Sec. 38a-491a. Coverage for in-patient, outpatient or one-day dental services in certain instances.

Sec. 38a-491b. Assignment of benefits to a dentist or oral surgeon.

Sec. 38a-492. (Formerly Sec. 38-174i). Coverage for accidental ingestion or consumption of controlled drugs. Benefits prescribed.

Sec. 38a-492a. Mandatory coverage for hypodermic needles and syringes.

Sec. 38a-492b. Coverage for off-label drug prescriptions.

Sec. 38a-492c. Coverage for low protein modified food products, amino acid modified preparations and specialized formulas.

Sec. 38a-492d. Mandatory coverage for diabetes testing and treatment.

Sec. 38a-492e. Mandatory coverage for diabetes outpatient self-management training.

Sec. 38a-492f. Mandatory coverage for certain prescription drugs removed from formulary.

Sec. 38a-492g. Mandatory coverage for prostate cancer screening and treatment.

Sec. 38a-492h. Mandatory coverage for certain Lyme disease treatments.

Sec. 38a-492i. Mandatory coverage for pain management.

Sec. 38a-492j. Mandatory coverage for ostomy-related supplies.

Sec. 38a-492k. Mandatory coverage for colorectal cancer screening.

Sec. 38a-492l. Mandatory coverage for neuropsychological testing for children diagnosed with cancer.

Sec. 38a-492m. Mandatory coverage for certain renewals of prescription eye drops.

Sec. 38a-492n. Mandatory coverage for certain wound-care supplies.

Sec. 38a-492o. Mandatory coverage for bone marrow testing.

Sec. 38a-493. (Formerly Sec. 38-174k). Mandatory coverage for home health care. Deductibles. Exception from deductible limits for medical savings accounts, Archer MSAs and health savings accounts.

Sec. 38a-494. (Formerly Sec. 38-174l). Home health care by recognized nonmedical systems.

Sec. 38a-495. (Formerly Sec. 38-174m). Medicare supplement policies. Coverage of home health aid services and mammography. Prescription drug riders.

Sec. 38a-495a. Medicare supplement policies and certificates. Minimum required policy benefits and standards. Regulations.

Sec. 38a-495b. Medicare supplement policies and certificates. Definitions.

Sec. 38a-495c. Medicare supplement premium rates charged on a community rate basis. Age, gender, previous claim or medical history rating prohibited. Preexisting conditions. Coverage for the disabled. Regulations.

Sec. 38a-495d. Refund of prepaid premium for Medicare supplement policies.

Sec. 38a-496. (Formerly Sec. 38-174q). Coverage for occupational therapy.

Sec. 38a-497. (Formerly Sec. 38-174r). Termination of coverage of children in individual policies. Coverage for stepchildren.

Sec. 38a-497a. Group coverage and benefits of a noncustodial parent. National Medical Support Notice. Notification of new employer by IV-D agency. Notification to parent. Enrollment of child.

Sec. 38a-498. (Formerly Sec. 38-174t). Mandatory coverage for medically necessary ambulance services. Direct payment to ambulance provider.

Sec. 38a-498a. Preauthorization prohibited for certain 9-1-1 emergency calls.

Sec. 38a-498b. Mandatory coverage for mobile field hospital.

Sec. 38a-498c. Denial of coverage prohibited for health care services rendered to persons with an elevated blood alcohol content.

Sec. 38a-499. (Formerly Sec. 38-174v). Mandatory coverage for services of physician assistants and certain nurses.

Sec. 38a-500. (Formerly Sec. 38-174w). Mandatory coverage for partners, sole proprietors and corporate officers for work-related injuries. Subrogation rights.

Sec. 38a-501. (Formerly Sec. 38-174x). Long-term care policies.

Sec. 38a-502. (Formerly Sec. 38-174ff). Mandatory coverage for services provided by the Veterans’ Home.

Sec. 38a-503. (Formerly Sec. 38-174gg). Mandatory coverage for mammography, breast ultrasound and magnetic resonance imaging. Breast density information included in mammography report.

Sec. 38a-503a. Mandatory coverage for breast cancer survivors.

Sec. 38a-503b. Carriers to permit direct access to obstetrician-gynecologist.

Sec. 38a-503c. Mandatory coverage for maternity care. Notice required.

Sec. 38a-503d. Mandatory coverage for mastectomy care. Termination of provider contract prohibited.

Sec. 38a-503e. Mandatory coverage for prescription contraceptives.

Sec. 38a-504. (Formerly Sec. 38-262i). Mandatory coverage for treatment of tumors and leukemia. Mandatory coverage for reconstructive surgery, prosthesis, chemotherapy and wigs. Orally administered anticancer medications.

Sec. 38a-504a. Coverage for routine patient care costs associated with certain clinical trials.

Sec. 38a-504b. Clinical trial criteria.

Sec. 38a-504c. Evidence and information re eligibility for clinical trial. No coverage required for otherwise reimbursable costs.

Sec. 38a-504d. Clinical trials: Routine patient care costs.

Sec. 38a-504e. Clinical trials: Billing. Payments.

Sec. 38a-504f. Clinical trials: Standardized forms. Time frame for coverage determinations. Appeals. Regulations.

Sec. 38a-504g. Clinical trials: Submission and certification of policy forms.

Sec. 38a-505. (Formerly Sec. 38-378). Insurance Commissioner’s powers concerning comprehensive health care plans. Notification to purchasers of policy.

Sec. 38a-506. (Formerly Sec. 38-173). Penalty.

Sec. 38a-507. Coverage for services performed by chiropractors.

Sec. 38a-508. Coverage for adopted children.

Sec. 38a-509. Mandatory coverage for infertility diagnosis and treatment. Limitations.

Sec. 38a-510. Prescription drug coverage. Mail order pharmacies.

Sec. 38a-511. Copayments re in-network imaging services.

Sec. 38a-512. Applicability of statutes to certain major medical expense policies.

Sec. 38a-512a. Continuation of coverage.

Sec. 38a-512b. Termination of coverage of children in group policies. Coverage for stepchildren.

Sec. 38a-512c. Lifetime limit.

Sec. 38a-513. Approval of group health insurance policies and certificates. Medicare supplement policies and certificates: Age, gender, previous claim or medical history rating prohibited. Optional life insurance riders. Regulations. Group specified disease policies.

Sec. 38a-513a. Time limits for coverage determinations. Notice requirements.

Sec. 38a-513b. Coverage and notice re experimental treatments. Appeals.

Sec. 38a-513c. Group health insurance policy to contain definition of “medically necessary” or “medical necessity”.

Sec. 38a-513d. Insurers prohibited from issuing policy with limited coverage to employer as replacement for a comprehensive health insurance plan. Disclosure required in policy providing limited coverage. Limited coverage defined.

Sec. 38a-513e. Premium payment by employer following employee termination. Exceptions. Right to continuation of coverage following relocation or closing of covered establishment not affected.

Sec. 38a-513f. Claims information to be provided to certain employers. Restrictions. Subpoenas.

Sec. 38a-513g. Employer submission of plan cost information to Comptroller.

Sec. 38a-514. (Formerly Sec. 38-174d). Mandatory coverage for the diagnosis and treatment of mental or nervous conditions. Exceptions. Benefits payable re type of provider or facility. State’s claim against proceeds.

Sec. 38a-514a. Biologically-based mental illness. Coverage required.

Sec. 38a-514b. Coverage for autism spectrum disorder.

Sec. 38a-515. Continuation of coverage of mentally or physically handicapped children.

Sec. 38a-516. Coverage for newly born children. Notification to insurer.

Sec. 38a-516a. Coverage for birth-to-three program.

Sec. 38a-516b. Coverage for hearing aids for children twelve and under.

Sec. 38a-516c. Coverage for craniofacial disorders.

Sec. 38a-516d. Coverage for neuropsychological testing for children diagnosed with cancer.

Sec. 38a-517. Coverage for services performed by dentist in certain instances.

Sec. 38a-517a. Coverage for in-patient, outpatient or one-day dental services in certain instances.

Sec. 38a-517b. Assignment of benefits to a dentist or oral surgeon.

Sec. 38a-518. Coverage for accidental ingestion or consumption of controlled drugs. Benefits prescribed.

Sec. 38a-518a. Mandatory coverage for hypodermic needles and syringes.

Sec. 38a-518b. Coverage for off-label drug prescriptions.

Sec. 38a-518c. Coverage for low protein modified food products, amino acid modified preparations and specialized formulas.

Sec. 38a-518d. Mandatory coverage for diabetes testing and treatment.

Sec. 38a-518e. Mandatory coverage for diabetes outpatient self-management training.

Sec. 38a-518f. Mandatory coverage for certain prescription drugs removed from formulary.

Sec. 38a-518g. Mandatory coverage for prostate cancer screening and treatment.

Sec. 38a-518h. Mandatory coverage for certain Lyme disease treatments.

Sec. 38a-518i. Mandatory coverage for pain management.

Sec. 38a-518j. Mandatory coverage for ostomy-related supplies.

Sec. 38a-518k. Mandatory coverage for colorectal cancer screening.

Sec. 38a-518l. Mandatory coverage for certain renewals of prescription eye drops.

Sec. 38a-518m. Mandatory coverage for certain wound-care supplies.

Sec. 38a-518n. Reserved

Sec. 38a-518o. Mandatory coverage for bone marrow testing.

Sec. 38a-519. (Formerly Sec. 38-174j). Offset proviso prohibited in certain policies. Required disclosures for group long-term disability policies.

Sec. 38a-520. Mandatory coverage for home health care. Deductibles. Exception from deductible limits for medical savings accounts. Archer MSAs and health savings accounts.

Sec. 38a-521. Home health care by recognized nonmedical systems.

Sec. 38a-522. Medicare supplement policies. Coverage of home health aide service.

Sec. 38a-523. (Formerly Sec. 38-174p). Group hospital or medical insurance coverage for comprehensive rehabilitation services.

Sec. 38a-524. Coverage for occupational therapy.

Sec. 38a-525. Mandatory coverage for medically necessary ambulance services. Direct payment to ambulance provider.

Sec. 38a-525a. Preauthorization prohibited for certain 9-1-1 emergency calls.

Sec. 38a-525b. Mandatory coverage for mobile field hospital.

Sec. 38a-525c. Denial of coverage prohibited for health care services rendered to persons with an elevated blood alcohol content.

Sec. 38a-526. Mandatory coverage for services of physician assistants and certain nurses.

Sec. 38a-527. Mandatory coverage for partners, sole proprietors and corporate officers for work-related injuries.

Sec. 38a-528. Long-term care policies.

Sec. 38a-529. Mandatory coverage for services provided by the Veterans’ Home.

Sec. 38a-530. Mandatory coverage for mammography, breast ultrasound and magnetic resonance imaging. Breast density information included in mammography report.

Sec. 38a-530a. Mandatory coverage for breast cancer survivors.

Sec. 38a-530b. Carriers to permit direct access to obstetrician-gynecologist.

Sec. 38a-530c. Mandatory coverage for maternity care. Notice required.

Sec. 38a-530d. Mandatory coverage for mastectomy care. Termination of provider contract prohibited.

Sec. 38a-530e. Mandatory coverage for prescription contraceptives.

Sec. 38a-531. (Formerly Sec. 38-174hh). Mandatory coverage for employees of certain employers. Approval of policy forms.

Sec. 38a-532. (Formerly Sec. 38-262a). Assignment of incidents of ownership under group life, health or accident policy.

Sec. 38a-533. (Formerly Sec. 38-262b). Mandatory coverage for the treatment of medical complications of alcoholism.

Sec. 38a-534. Coverage for services performed by chiropractors.

Sec. 38a-535. Mandatory coverage for preventive pediatric care and blood lead screening and risk assessment.

Sec. 38a-535a. Notification of individual coverage and benefits of a noncustodial parent to a custodial parent, when. Regulations.

Sec. 38a-536. Mandatory coverage for infertility diagnosis and treatment. Limitations.

Sec. 38a-537. (Formerly Sec. 38-262c). Notice of cancellation or discontinuation to covered employees. Fine. Notice of transfer of coverage. Failure to procure coverage. Retroactive coverage.

Sec. 38a-538. (Formerly Sec. 38-262d). Continuation of benefits under group employee health plans.

Sec. 38a-539. (Formerly Sec. 38-262f). Group hospital or medical expense insurance policy coverage for treatment of alcoholism on an outpatient basis.

Sec. 38a-540. (Formerly Sec. 38-262g). Duplication of coverage under group health insurance policies.

Sec. 38a-541. (Formerly Sec. 38-262h). Group health policy to allow spouse coverage as both employee and dependent, when. Effect of collective bargaining agreements.

Sec. 38a-542. Mandatory coverage for treatment of tumors and leukemia. Mandatory coverage for reconstructive surgery, prosthesis, chemotherapy and wigs. Orally administered anticancer medications.

Sec. 38a-542a. Coverage for routine patient care costs associated with certain clinical trials.

Sec. 38a-542b. Clinical trial criteria.

Sec. 38a-542c. Evidence and information re eligibility for clinical trial. No coverage required for otherwise reimbursable costs.

Sec. 38a-542d. Clinical trials: Routine patient care costs.

Sec. 38a-542e. Clinical trials: Billing. Payments.

Sec. 38a-542f. Clinical trials: Standardized forms. Time frame for coverage determinations. Appeals. Regulations.

Sec. 38a-542g. Clinical trials: Submission and certification of policy forms.

Sec. 38a-543. (Formerly Sec. 38-262j). Age discrimination in group insurance coverage prohibited.

Sec. 38a-544. Prescription drug coverage. Mail order pharmacies.

Sec. 38a-545. (Formerly Sec. 38-262k). Group dental health insurance plans. Alternative coverage option.

Sec. 38a-546. (Formerly Sec. 38-379). Discontinuation and replacement of group health insurance policy. Regulations.

Sec. 38a-547. Termination of policy or contract due to insurer ceasing to offer health insurance in this state; maternity benefits to continue for six weeks following termination of the pregnancy, when.

Sec. 38a-548. Penalty.

Sec. 38a-549. Coverage for adopted children.

Sec. 38a-550. Copayments re in-network imaging services.

Sec. 38a-551. (Formerly Sec. 38-371). Definitions.

Sec. 38a-552. (Formerly Sec. 38-372). Applicability. Individual and group comprehensive health care plans.

Sec. 38a-553. (Formerly Sec. 38-373). Minimum standard benefits of comprehensive health care plans. Optional and excludable benefits. Preexisting conditions. Use of managed care plans.

Sec. 38a-554. (Formerly Sec. 38-374). Additional requirements and eligibility under group comprehensive health care plans. Coverage for stepchildren. Continuation of benefits under group plans. Insurance Commissioner’s authority to coordinate benefits.

Sec. 38a-555. (Formerly Sec. 38-375). Additional requirements for individual comprehensive health care plans. Carrier obligations concerning termination of coverage.

Sec. 38a-556. (Formerly Sec. 38-376). Health Reinsurance Association. Classes of risk. Audits. Insurance Commissioner’s powers. Qualification as an acceptable alternative mechanism.

Sec. 38a-556a. Connecticut Clearinghouse.

Sec. 38a-557. (Formerly Sec. 38-377). Hospital and medical service corporations. Residual market mechanism. Insurance Commissioner’s powers concerning such mechanisms.

Sec. 38a-558. (Formerly Sec. 38-380). Office of Health Care Access.

Sec. 38a-559. (Formerly Sec. 38-381). Commissioner of Social Services. Contract authority concerning Medicaid programs.

Secs. 38a-560. Small employer grouping for health insurance coverage.

Secs. 38a-561 to 38a-563. Reserved

Sec. 38a-564. Definitions.

Sec. 38a-565. Special health care plans.

Sec. 38a-566. Health insurance plans or insurance arrangements covering employees of a small employer. Trusts. Trade associations. Self-employed individuals.

Sec. 38a-567. Provisions of small employer plans and arrangements.

Sec. 38a-568. Coverage under small employer health care plans and arrangements. Approval by commissioner.

Sec. 38a-569. Connecticut Small Employer Health Reinsurance Pool.

Sec. 38a-570. Issuance of special health care plans by the Health Reinsurance Association to small employers.

Sec. 38a-571. Issuance of individual special health care plans by the Health Reinsurance Association.

Sec. 38a-572. Requirement to provide service to certain low-income persons.

Sec. 38a-573. Validity of separate provisions.

Sec. 38a-574. Standard underwriting form.

Secs. 38a-575 and 38a-576. Reserved

Sec. 38a-577. (Formerly Sec. 38-174ii). Consumer dental health plans. Definitions.

Sec. 38a-578. (Formerly Sec. 38-174jj). Certificate of authority. Application requirements.

Sec. 38a-579. (Formerly Sec. 38-174kk). Certificate of authority. Standards for issuance and renewal.

Sec. 38a-580. (Formerly Sec. 38-174ll). General surplus required.

Sec. 38a-581. (Formerly Sec. 38-174mm). Evidence of coverage to be provided to enrollees. Approval by commissioner.

Sec. 38a-582. (Formerly Sec. 38-174nn). Schedule of charges. Approval by commissioner. Appeal of disapproval.

Sec. 38a-583. (Formerly Sec. 38-174oo). Records. Commissioner’s power to examine; maintenance; preservation.

Sec. 38a-584. (Formerly Sec. 38-174pp). Complaint system.

Sec. 38a-585. (Formerly Sec. 38-174qq). Requirements re filing of annual reports with commissioner.

Sec. 38a-586. (Formerly Sec. 38-174rr). False or misleading advertising or solicitation and deceptive evidence of coverage prohibited.

Sec. 38a-587. (Formerly Sec. 38-174ss). Suspension or revocation of certificate of authority. Hearing. Appeal.

Sec. 38a-588. (Formerly Sec. 38-174tt). Penalty. Insolvency.

Sec. 38a-589. (Formerly Sec. 38-174uu). Confidentiality.

Sec. 38a-590. (Formerly Sec. 38-174vv). Commissioner’s power to adopt regulations.

Sec. 38a-591. Compliance with the Patient Protection and Affordable Care Act. Regulations.

Sec. 38a-591a. Definitions.

Sec. 38a-591b. Health carrier responsibilities re utilization review. Disclosures. Annual report. Regulations.

Sec. 38a-591c. Utilization review criteria and procedures.

Sec. 38a-591d. Utilization review and benefit determinations. Urgent care requests. Information provided in notice of adverse determination.

Sec. 38a-591e. Internal grievance process of adverse determinations based on medical necessity. Expedited review of adverse determinations of urgent care requests.

Sec. 38a-591f. Internal grievance process of adverse determinations not based on medical necessity.

Sec. 38a-591g. External reviews and expedited external reviews.

Sec. 38a-591h. Record-keeping requirements. Report to commissioner upon request.

Sec. 38a-591i. Regulations.

Sec. 38a-591j. Utilization review companies: Licensure. Fees. Investigation of grievances. Duties.

Sec. 38a-591k. Violations. Notice and hearing. Penalties. Appeal.

Sec. 38a-591l. Independent review organizations conducting external reviews and expedited external reviews.

Sec. 38a-591m. Independent review organizations: Conflicts of interest. Liability. Record-keeping requirements. Report to commissioner upon request.

Sec. 38a-591n. Documents, communications, information and evidence provided to covered person or covered person’s authorized representative upon request.

Secs. 38a-592 to 38a-594. Reserved


PART I

HEALTH INSURANCE: IN GENERAL

Sec. 38a-469. Definitions. As used in this title, unless the context otherwise requires or a different meaning is specifically prescribed, “health insurance” policy means insurance providing benefits due to illness or injury, resulting in loss of life, loss of earnings, or expenses incurred, and includes the following types of coverage: (1) Basic hospital expense coverage; (2) basic medical-surgical expense coverage; (3) hospital confinement indemnity coverage; (4) major medical expense coverage; (5) disability income protection coverage; (6) accident only coverage; (7) long term care coverage; (8) specified accident coverage; (9) Medicare supplement coverage; (10) limited benefit health coverage; (11) hospital or medical service plan contract; (12) hospital and medical coverage provided to subscribers of a health care center; (13) specified disease coverage; (14) TriCare supplement coverage; (15) travel health coverage; and (16) single service ancillary health coverage, including, but not limited to, dental, vision or prescription drug coverage.

(P.A. 90-243, S. 68; P.A. 96-227, S. 9; P.A. 08-147, S. 5; Sept. Sp. Sess. P.A. 09-7, S. 171.)

History: P.A. 96-227 added “specified disease coverage” as a type of “health insurance” policy; (Revisor’s note: In 2005 the words “title 38a” were replaced editorially by the Revisors with “this title”); P.A. 08-147 added Subdiv. (14) to include TriCare supplement coverage in definition of “health insurance” policy; Sept. Sp. Sess. P.A. 09-7 added Subdiv. (15) re travel health coverage and Subdiv. (16) re single service ancillary health coverage as types of health insurance policies.

Sec. 38a-470. (Formerly Sec. 38-174n). Lien on workers’ compensation awards for insurers. Notice of lien. (a) For purposes of this section, “controverted claim” means any claim in which compensation is denied either in whole or in part by the workers’ compensation carrier or the employer, if self-insured.

(b) Any insurer, hospital or medical service corporation, health care center or employee welfare benefit plan which furnished benefits or services under a health insurance policy or a self-insured employee welfare benefit plan to any person suffering an injury or illness covered by the Workers’ Compensation Act has a lien on the proceeds of any award or approval of any compromise made by a workers’ compensation commissioner less attorneys’ fees approved by the district commissioner and reasonable costs related to the proceeding, to the extent of benefits paid or services provided for the effects of the injury or illness arising out of and in the course of employment as a result of a controverted claim, provided such plan, policy or contract provides for reduction, exclusion, or coordination of benefits of the policy or plan on account of workers’ compensation benefits.

(c) The lien shall arise at the time such benefits are paid or such services are rendered. The person or entity furnishing such benefits or services shall serve written notice upon the employee, the insurance company providing workers’ compensation benefits or the employer, if self-insured, and the workers’ compensation commissioner for the district in which the claim for workers’ compensation has been filed, setting forth the nature and extent of the lien allowable under subsection (b) of this section. The lien shall be effective against any workers’ compensation award made after the notice is received.

(d) The written notice shall be served upon the employee at his last-known address, the insurance company at its principal place of business in this state or the employer, if self-insured, at its principal place of business, and the workers’ compensation commissioner, at the district office. Service shall be made to all parties by certified or registered mail. The notice shall be in duplicate and shall contain, in addition to the information set forth in subsection (c) of this section, the name of the injured or ill employee, the name of the company providing workers’ compensation benefits, the amount expended and an estimate of the amount to be expended for benefits or services provided to such injured or ill employee.

(e) The insurance company providing workers’ compensation coverage or the employer, if self-insured, shall reimburse the insurance company, hospital or medical service corporation, health care center or employee welfare benefit plan providing benefits or service directly, to the extent of any such lien. The receipt of such reimbursement by such insurer, hospital or medical service corporation, health care center or employee welfare benefit plan shall fully discharge such lien.

(f) The validity or amount of the lien may be contested by the workers’ compensation carrier, the employer, if self-insured or the employee by bringing an action in the superior court for the judicial district of Hartford or in the judicial district in which the plaintiff resides. Such cases shall have the same privilege with respect to their assignment for trial as appeals from the workers’ compensation review division but shall first be claimed for the short calendar unless the court shall order the matter placed on the trial list. An appeal may be taken from the decision of the Superior Court to the Appellate Court in the same manner as is provided in section 51-197b. In any appeal in which one of the parties is not represented by counsel and in which the party taking the appeal does not claim the case for the short calendar or trial within a reasonable time after the return day, the court may of its own motion dismiss the appeal, or the party ready to proceed may move for nonsuit or default as appropriate. During the pendency of the appeal any workers’ compensation benefits due shall be paid into the court in accordance with the rules relating to interpleader actions.

(P.A. 81-386, S. 1; June Sp. Sess. P.A. 83-29, S. 34, 82; P.A. 88-230, S. 1, 12; P.A. 90-98, S. 1, 2; 90-243, S. 69; P.A. 93-142, S. 4, 7, 8; P.A. 95-220, S. 4–6; P.A. 09-74, S. 25.)

History: June Sp. Sess. P.A. 83-29 deleted reference to supreme court and substituted appellate court in lieu thereof in Subsec. (f); P.A. 88-230 replaced “judicial district of Hartford-New Britain” with “judicial district of Hartford”, effective September 1, 1991; P.A. 90-98 changed the effective date of P.A. 88-230 from September 1, 1991, to September 1, 1993; P.A. 90-243 added references to “health care center” and substituted reference to “health insurance policies” for reference to various health, disability and accident policies; Sec. 38-174n transferred to Sec. 38a-470 in 1991; P.A. 93-142 changed the effective date of P.A. 88-230 from September 1, 1993, to September 1, 1996, effective June 14, 1993; P.A. 95-220 changed the effective date of P.A. 88-230 from September 1, 1996, to September 1, 1998, effective July 1, 1995; P.A. 09-74 made a technical change in Subsec. (c), effective May 27, 2009.

See Secs. 38a-199 to 38a-209, inclusive, re hospital service corporations.

See Secs. 38a-214 to 38a-225, inclusive, re medical service corporations.

Annotations to former section 38-174n:

Cited. 216 C. 815. Cited. 219 C. 439.

Cited. 22 CA 539; judgment reversed, see 219 C. 439.

Subsec. (b):

Cited. 217 C. 631.

Cited. 22 CA 27; judgment reversed, see 217 C. 631.

Annotations to present section:

Cited. 219 C. 439.

Subsec. (b):

Cited. 217 C. 631.

Sec. 38a-471. (Formerly Sec. 38-174o). Third party prescription programs. Notice of cancellation. Applicability of section. (a) As used in this section, a “third party prescription program” means a system of providing for reimbursement for the cost of drugs or pharmaceutical services under a contractual arrangement or agreement with a provider of such drugs or services. Such programs shall include, but not be limited to, employee benefit plans under which a consumer receives prescription drugs or pharmaceutical services and such drugs or services are paid for in part by an agent of the consumer’s employer or others. An “administrator” means the program administrator of a third party prescription program.

(b) Any agreement or contract entered into in this state between an administrator and a pharmacy shall include a statement of the method and amount of reimbursement to the pharmacy for drugs or services provided to persons enrolled in the program, and the frequency of payment by the administrator to the pharmacy for such drugs or services.

(c) (1) Each administrator of a program shall notify all pharmacies enrolled in such program of any cancellation of coverage or benefits of any group enrolled in the program at least thirty days prior to the effective date of such cancellation or within ten business days following the date on which he receives notice of a cancellation, if he receives such notice less than forty days prior to its effective date.

(2) Each employer shall give written notice to all persons enrolled in such program of the cancellation of the plan and written notice to any person whose enrollment is terminated. Such notice shall be given as soon as is practicable but in no case later than thirty days after cancellation or termination. Such notice shall include a demand for the return of any plan identification cards such persons may have been issued by reason of their enrollment in such program.

(3) Any person who uses a program identification card to obtain drugs or services from a pharmacy after having received notice of the cancellation of his program shall be liable to the administrator for all moneys paid by the administrator for any drugs or services obtained by the illegal use of such card.

(d) (1) No administrator shall deny payment to any pharmacy for drugs or services which were provided as the result of the fraudulent or illegal use of an identification card by any person to whom an identification card was issued, unless the pharmacy was notified of the cancellation of such card.

(2) No administrator shall withhold payments for uncontested claims to any pharmacy beyond the time period specified in the payment schedule provisions of the agreement.

(e) Each administrator shall mail to any pharmacist, upon written request, a copy of each contract or agreement form in use in this state between such administrator and a pharmacy.

(f) No administrator shall prohibit a pharmacy from enrolling in a program except for cause, including, but not limited to, previous fraudulent use of program identification cards.

(g) The provisions of this section shall not apply to the providing of drugs or services under the provisions of Title XIX of the Social Security Act.

(P.A. 81-455, S. 1–8.)

History: Sec. 38-174o transferred to Sec. 38a-471 in 1991.

Sec. 38a-472. (Formerly Sec. 38-174a). Assignment of insurance proceeds to doctor, hospital or state agency. Lien for state care. Notice of lien. (a) Whenever a contract by a third party agency provides for payment to a beneficiary under the contract on account of bills incurred by him for medical, surgical or hospital care received by him, the assignment of the benefits of the contract by that beneficiary to the department head, as defined in section 4-5, of a state agency, or any doctor or hospital rendering such care, when sent by registered or certified mail to the third party agency, with a copy to the insured, shall be authority for the payment directly by the third party agency to the assignee. The state shall have a lien, in an amount equal to the care rendered, on the proceeds of such contracts for care rendered by any state hospital, institution or other facility, written notice of which shall be authority for the payment directly by the third party agency to the state.

(b) Whenever there is in existence a contract by an insurer for payment to, or on behalf of, an applicant or recipient of medical assistance under the Medicaid program under said contract on account of bills incurred by the applicant or recipient for medical services, including, but not limited to, physician services, nursing services, pharmaceutical services, surgical care and hospital care, the assignment of the benefits of the contract by such applicant or recipient or his legally liable relative pursuant to section 17b-265 shall, upon receipt of notice from the assignee, be authority for payment by the insurer directly to the assignee. If notice is provided by the assignee to the insurer in accordance with the provisions of section 17b-265, the insurer shall be liable to the assignee for any amount payable to the assignee under the contract.

(c) No insurer, health care center or issuer of any service plan contract for hospital or medical expense coverage delivered, issued for delivery or renewed in this state shall impose requirements on the Department of Social Services which have the effect of denying or limiting benefits which have been assigned pursuant to this section. The assignment of benefits shall be in accordance with the provisions of section 38a-472.

(1961, P.A. 124; P.A. 75-591; P.A. 90-243, S. 70; 90-283, S. 2; May Sp. Sess. P.A. 94-5, S. 8, 30; June 18 Sp. Sess. P.A. 97-2, S. 101, 165; P.A. 04-76, S. 36; P.A. 11-44, S. 136.)

History: P.A. 75-591 clarified existing provision by substituting “sent by registered or certified mail” for “lodged with”, authorized assignment of benefits to department heads, required a copy to be sent to insured and added provision re state’s lien on contracts for care rendered by state hospitals, institutions, etc.; P.A. 90-243 made technical changes for statutory consistency; P.A. 90-283 added Subsec. (b) re assignment of benefits of contract by an applicant or recipient of medical assistance; Sec. 38-174a transferred to Sec. 38a-472 in 1991; May Sp. Sess. P.A. 94-5 added a new Subsec. (c) to prevent insurers from imposing requirements on the department of social services which deny or limit benefits assigned pursuant to this section, effective July 1, 1994; June 18 Sp. Sess. P.A. 97-2 amended Subsec. (b) to make technical and conforming changes to references re assistance programs, effective July 1, 1997; P.A. 04-76 amended Subsec. (b) by deleting reference to “general assistance program”; P.A. 11-44 amended Subsec. (b) by deleting “the state-administered general assistance program or”, effective July 1, 2011.

Annotation to former section 38-174a:

Subsec. (b):

Cited. 219 C. 439.

Annotation to present section:

Cited. 219 C. 439.

Sec. 38a-472a. Medical provider indemnification agreements prohibited. No contract between a managed care company, other organization or insurer authorized to do business in this state and a medical provider practicing in this state for the provision of services may require that the medical provider indemnify the managed care company, other organization or insurer for any expenses and liabilities including, without limitation, judgments, settlements, attorneys’ fees, court costs and any associated charges incurred in connection with any claim or action brought against a managed care company, other organization or insurer on the basis of its determination of medical necessity or appropriateness of health care services if the information provided by said medical provider used in making the determination was accurate and appropriate at the time it was given. As used in this section and section 38a-472b, “medical provider” means any person licensed pursuant to chapters 370 to 373, inclusive, or chapter 375, 379, 380 or 383.

(P.A. 95-199, S. 3.)

Sec. 38a-472b. Medical provider indemnification contracts. Professional actions and related liability. Notwithstanding the provisions of section 38a-472a, every medical provider participating in a contract pursuant to said section shall be responsible for his professional actions and related liability.

(P.A. 95-199, S. 4.)

Sec. 38a-472c. Dental policies. Estimate of reimbursement. For any policy delivered, issued for delivery, renewed, amended or continued in this state that provides coverage for inpatient or outpatient dental services only, the person who issues the policy shall provide the insured or a licensed dentist acting on behalf of the insured, upon request, an estimate of reimbursement under the policy with respect to specific dental procedure codes ordered or recommended for the insured by a licensed dentist, except that the actual reimbursement may be adjusted based on factors such as the insured’s eligibility, plan design, utilization of benefits and the actual claim submitted.

(P.A. 04-125, S. 1; P.A. 11-19, S. 7.)

History: P.A. 11-9 made a technical change.

Sec. 38a-472d. Public education outreach program re health insurance availability and eligibility requirements. (a) Not later than January 1, 2006, the Insurance Commissioner, in consultation with the Commissioner of Social Services and the Healthcare Advocate, shall develop a comprehensive public education outreach program to educate health insurance consumers about the availability and general eligibility requirements of various health insurance options in this state. The program shall maximize public information concerning health insurance options in this state and shall provide for the dissemination of such information on the Insurance Department’s Internet web site.

(b) The information on the department’s Internet web site shall reference the availability and general eligibility requirements of (1) programs administered by the Department of Social Services, including, but not limited to, the Medicaid program and the HUSKY Plan, Part A and Part B, (2) health insurance coverage provided by the Comptroller under subsection (i) of section 5-259, (3) health insurance coverage available under comprehensive health care plans issued pursuant to part IV of this chapter, and (4) other health insurance coverage offered through local, state or federal agencies or through entities licensed in this state. The commissioner shall update the information on the web site at least quarterly.

(P.A. 05-253, S. 1; P.A. 11-44, S. 137.)

History: P.A. 11-44 amended Subsec. (b)(1) by deleting “the state-administered general assistance program” and making technical changes, effective July 1, 2011.

Sec. 38a-472e. Health insurer. Requirements re offer to contract with a school-based health center. Each health insurer licensed to do business in this state shall, at the request of any school-based health center or group of school-based health centers, offer to contract with such center or centers to provide reimbursement for covered health care services to persons who are insured by such licensed insurer. Such offer shall be made on terms and conditions similar to contracts offered to other providers of health care services.

(P.A. 10-118, S. 1.)

History: P.A. 10-118 effective June 7, 2010.

Sec. 38a-472f. Provider network adequacy. Each insurer, health care center, managed care organization or other entity that delivers, issues for delivery, renews, amends or continues an individual or group health insurance policy or medical benefits plan, and each preferred provider network, as defined in section 38a-479aa, that contracts with a health care provider, as defined in section 38a-478, for the purposes of providing covered health care services to its enrollees, shall maintain a network of such providers that is consistent with the National Committee for Quality Assurance’s network adequacy requirements or URAC’s provider network access and availability standards.

(P.A. 11-58, S. 17.)

History: P.A. 11-58 effective January 1, 2012.

Sec. 38a-472g. Restrictions applicable to preauthorization or precertification. (a)(1) No insurer, health care center, fraternal benefit society, hospital service corporation or medical service corporation or other entity, delivering, issuing for delivery, renewing, amending or continuing an individual or group health insurance policy in this state providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 or utilization review company performing utilization review for such insurer, center, society, corporation or entity, that preauthorizes or precertifies, on or after January 1, 2012, an admission, service, procedure or extension of stay shall reverse or rescind such preauthorization or precertification or refuse to pay for such admission, service, procedure or extension of stay if:

(A) Such insurer, center, society, corporation, entity or company failed to notify the insured’s or enrollee’s health care provider at least three business days prior to the scheduled date of such admission, service, procedure or extension of stay that such preauthorization or precertification has been reversed or rescinded on the basis of medical necessity, fraud or lack of coverage; and

(B) Such admission, service, procedure or extension of stay has taken place in reliance on such preauthorization or precertification.

(2) The provisions of this subsection shall apply regardless of whether such preauthorization or precertification is required or is requested by an insured’s or enrollee’s health care provider. Unless reversed or rescinded as set forth in subparagraph (A) of subdivision (1) of this subsection, such preauthorization or precertification shall be effective for not less than sixty days from the date of issuance.

(b) Nothing in subsection (a) of this section shall be construed to authorize benefits or services in excess of those that are provided for in the insured’s or enrollee’s policy or contract.

(c) Nothing in subsection (a) of this section shall affect the provisions of subsection (b) of section 38a-479b.

(P.A. 11-58, S. 18.)

History: P.A. 11-58 effective January 1, 2012.

Sec. 38a-472h. Dental fees for noncovered benefits. Posting required by dentists. Exceptions. (a) No insurer, health care center, fraternal benefit society, hospital service corporation, medical service corporation or other entity delivering, issuing for delivery, renewing, amending or continuing an individual or group dental plan in this state shall include in any contract with a dentist licensed pursuant to chapter 379 that is entered into, renewed or amended on or after January 1, 2012, any provision that requires such dentist to accept as payment an amount set by such insurer, center, society, corporation or entity for services or procedures provided to an insured or enrollee that are not covered benefits under such insured’s or enrollee’s plan.

(b) A dentist shall not charge more for services or procedures that are not covered benefits than such dentist’s usual and customary rate for such services or procedures.

(c) Each evidence of coverage for an individual or group dental plan shall include the following statement:

“IMPORTANT: If you opt to receive dental services or procedures that are not covered benefits under this plan, a participating dental provider may charge you his or her usual and customary rate for such services or procedures. Prior to providing you with dental services or procedures that are not covered benefits, the dental provider should provide you with a treatment plan that includes each anticipated service or procedure to be provided and the estimated cost of each such service or procedure. To fully understand your coverage, you may wish to review your evidence of coverage document.”

(d) Each dentist shall post, in a conspicuous place, a notice stating that services or procedures that are not covered benefits under an insurance policy or plan might not be offered at a discounted rate.

(e) The provisions of this section shall not apply to (1) a self-insured plan that covers dental services, or (2) a contract that is incorporated in or derived from a collective bargaining agreement or in which some or all of the material terms are subject to a collective bargaining process.

(P.A. 11-58, S. 19; P.A. 12-145, S. 9.)

History: P.A. 11-58 effective January 1, 2012; P.A. 12-145 made a technical change in Subsec. (a), effective June 15, 2012.

Sec. 38a-472i. Payment amount of professional services component of covered colonoscopy or endoscopic services. Each insurer, health care center, hospital service corporation, medical service corporation or fraternal benefit society that delivers, issues for delivery, renews, amends or continues an individual or group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 in this state, and contracts directly with a physician or physician group or physician organization to provide medical services under such policy shall, at such contracted physician’s or physician’s group’s or physician’s organization’s request, establish a payment amount for the physician’s professional services component of colonoscopy or endoscopic services covered under such policy, that is the same regardless of where the physician’s professional services are performed. Such payment amount for the physician’s professional services shall not be less than the amount that would otherwise be paid to such contracted physician or physician group or physician organization if the services are performed at a facility other than an outpatient surgical facility, as defined in section 19a-493b. Nothing in this section shall prohibit a contracted physician or physician group or physician organization from agreeing to a different payment methodology for colonoscopy or endoscopic services.

(P.A. 11-225, S. 3.)

See Secs. 38a-492k and 38a-518k for individual and group health insurance coverage for colorectal cancer screening.

Sec. 38a-473. Medicare supplement expense factors. Age, gender, previous claim or medical history rating prohibited. (a) No insurance company, fraternal benefit society, hospital service corporation, medical service corporation, health care center or other entity which delivers or issues for delivery Medicare supplement insurance policies or certificates, written, delivered, continued or renewed in this state during the previous calendar year shall incorporate in its rates for Medicare supplement insurance calculated in accordance with sections 38a-495, 38a-495a and 38a-522, and any regulations adopted pursuant to said sections, factors for expenses which exceed one hundred fifty per cent of the average expense ratio for the entire written premium for all lines of health insurance of such company, society, corporation, center or other entity for the previous calendar year.

(b) No insurance company, fraternal benefit society, hospital service corporation, medical service corporation, health care center or other entity which delivers or issues for delivery in this state any Medicare supplement policies or certificates shall incorporate in its rates or determinations to grant coverage for Medicare supplement insurance policies or certificates any factors or values based on the age, gender, previous claims history or the medical condition of any person covered by such policy or certificate.

(P.A. 90-243, S. 179, 181; P.A. 91-406, S. 9, 29; P.A. 92-60, S. 20; P.A. 93-239, S. 4; 93-390, S. 3, 8; May 25 Sp. Sess. P.A. 94-1, S. 39, 130; P.A. 05-20, S. 1; P.A. 11-19, S. 27.)

History: P.A. 91-406 corrected an internal reference; P.A. 92-60 made provisions applicable to any Medicare supplement policy continued or renewed during the previous calendar year, made provisions applicable to all lines of health insurance and made technical corrections for statutory consistency; P.A. 93-239 made technical corrections for statutory consistency and accuracy; P.A. 93-390 made technical changes for statutory consistency by adding references to “any other entity” and “certificate” and added Subsec. (b) prohibiting the incorporation of factors for age, gender and previous claim or medical condition history, into the insurer’s rate schedule, effective January 1, 1994; May 25 Sp. Sess. P.A. 94-1 amended Subsec. (a) by making technical change, effective July 1, 1994; P.A. 05-20 made technical changes and amended Subsec. (b) to reference “determinations to grant coverage” and plans “H” to “J”, inclusive, “issued prior to January 1, 2006” re use of claims history and medical condition, effective July 1, 2005; P.A. 11-19 amended Subsec. (b) to delete provisions re Medicare supplement plans “H” to “J”.

Sec. 38a-474. Medicare supplement policy rate increases: Procedure. Age, gender, previous claim or medical history rating prohibited. (a) Any insurance company, fraternal benefit society, hospital service corporation, medical service corporation, health care center or other entity which delivers, issues for delivery, renews, amends or continues in this state any Medicare supplement policy or certificate, as defined in sections 38a-495, 38a-495a and 38a-522, seeking to change its rates shall file a request for such change with the Insurance Department at least sixty days prior to the proposed effective date of such change. The Insurance Department shall review the request and, with respect to requests for an increase in rates, shall hold a public hearing on such increase. The Insurance Commissioner shall approve or deny the request not later than forty-five days after its receipt. The Insurance Commissioner shall adopt regulations, in accordance with chapter 54, to set requirements for the submission of data pertaining to a request to change rates and to define the policies utilized in making a decision on such change in rates.

(b) No insurance company, fraternal benefit society, hospital service corporation, medical service corporation, health care center or other entity which delivers or issues for delivery in this state any Medicare supplement policies or certificates shall incorporate in its rates or determinations to grant coverage for Medicare supplement insurance policies or certificates any factors or values based on the age, gender, previous claims history or the medical condition of the person covered by such policy or certificate.

(P.A. 90-81; P.A. 91-406, S. 10, 29; P.A. 93-390, S. 4, 8; P.A. 94-39, S. 4; P.A. 05-20, S. 2; P.A. 11-19, S. 28; P.A. 12-145, S. 53.)

History: P.A. 91-406 corrected an internal reference; P.A. 93-390 added references to “health care centers” and “any other entity” for statutory consistency and added Subsec. (b) prohibiting the incorporation of factors for age, gender and previous claim or medical condition history, into insurer’s rate schedule, effective January 1, 1994; P.A. 94-39 substituted “change” for the references to “increase” and added a provision in Subsec. (a) that with respect to requests for an increase in rates a public hearing must be held by the insurance department; P.A. 05-20 made technical changes and amended Subsec. (b) to reference “determinations to grant coverage” and plans “H” to “J”, inclusive, “issued prior to January 1, 2006” re use of claims history and medical condition, effective July 1, 2005; P.A. 11-19 amended Subsec. (b) to delete provisions re Medicare supplement plans “H” to “J”; P.A. 12-145 amended Subsec. (a) to add “amends” re policy or certificate, delete 1990 and 1994 date references, and make technical changes, effective January 1, 2013.

See Sec. 38a-481 re Medicare supplement policy rates.

Sec. 38a-475. Precertification of long-term care policies under the Connecticut Partnership for Long-Term Care. Regulations. The Insurance Department shall only precertify long-term care insurance policies which (1) alert the purchaser to the availability of consumer information and public education provided by the Department of Social Services pursuant to section 17b-251; (2) offer the option of home and community-based services in addition to nursing home care; (3) in all home care plans, include case management services delivered by an access agency approved by the Office of Policy and Management and the Department of Social Services as meeting the requirements for such agency as defined in regulations adopted pursuant to subsection (e) of section 17b-342, which services shall include, but need not be limited to, the development of a comprehensive individualized assessment and care plan and, as needed, the coordination of appropriate services and the monitoring of the delivery of such services; (4) provide inflation protection; (5) provide for the keeping of records and an explanation of benefit reports on insurance payments which count toward Medicaid resource exclusion; and (6) provide the management information and reports necessary to document the extent of Medicaid resource protection offered and to evaluate the Connecticut Partnership for Long-Term Care. No policy shall be precertified if it requires prior hospitalization or a prior stay in a nursing home as a condition of providing benefits. The commissioner may adopt regulations, in accordance with chapter 54, to carry out the precertification provisions of this section.

(P.A. 89-352, S. 3, 6; P.A. 91-187, S. 3, 4; P.A. 93-262, S. 1, 87; P.A. 95-160, S. 14, 69; P.A. 96-139, S. 12, 13; P.A. 04-10, S. 14; 04-257, S. 62.)

History: P.A. 91-187 amended Subdivs. (2), (3) and (4) to require all precertified policies to provide that the option of home and community-based services be offered in addition to nursing home care, that all home care plans include case management services and that all such policies provide inflation protection, deleting provision re option to furnish periodic per diem upgrades until insured begins receiving long-term care benefits; P.A. 93-262 authorized substitution of commissioner and department of social services for commissioner and department on aging, effective July 1, 1993; P.A. 95-160 replaced a reference to coordination, assessment and monitoring agencies with access agencies, effective July 1, 1995 (Revisor’s note: A reference to “Department of Insurance” was replaced editorially by the Revisors with “Insurance Department” for consistency with customary statutory usage); P.A. 96-139 changed effective date of P.A. 95-160 but without affecting this section; P.A. 04-10, effective October 1, 2004, and P.A. 04-257, effective June 14, 2004, both substituted “17b-251” for “17a-307”.

See Sec. 17b-251 re outreach program.

See Sec. 17b-252 re establishment of Connecticut Partnership for Long-Term Care pilot program.

See Sec. 17b-253 re amendments to Medicaid regulations and state plan, and regulations re determining eligibility of applicants for Medicaid and coverage requirements for long-term care benefits.

See Sec. 17b-254 re foundation funds and federal approval and report to General Assembly.

Sec. 38a-476. Preexisting condition coverage. (a)(1) For the purposes of this section, “health insurance plan” means any hospital and medical expense incurred policy, hospital or medical service plan contract and health care center subscriber contract and does not include (A) short-term health insurance issued on a nonrenewable basis with a duration of six months or less, accident only, credit, dental, vision, Medicare supplement, long-term care or disability insurance, hospital indemnity coverage, coverage issued as a supplement to liability insurance, insurance arising out of a workers’ compensation or similar law, automobile medical payments insurance, or insurance under which beneficiaries are payable without regard to fault and which is statutorily required to be contained in any liability insurance policy or equivalent self-insurance, or (B) policies of specified disease or limited benefit health insurance, provided that the carrier offering such policies files on or before March first of each year a certification with the Insurance Commissioner that contains the following: (i) A statement from the carrier certifying that such policies are being offered and marketed as supplemental health insurance and not as a substitute for hospital or medical expense insurance; (ii) a summary description of each such policy including the average annual premium rates, or range of premium rates in cases where premiums vary by age, gender or other factors, charged for such policies in the state; and (iii) in the case of a policy that is described in this subparagraph and that is offered for the first time in this state on or after October 1, 1993, the carrier files with the commissioner the information and statement required in this subparagraph at least thirty days prior to the date such policy is issued or delivered in this state.

(2) “Insurance arrangement” means any “multiple employer welfare arrangement”, as defined in Section 3 of the Employee Retirement Income Security Act of 1974 (ERISA), as amended, except for any such arrangement which is fully insured within the meaning of Section 514(b)(6) of said act, as amended.

(3) “Preexisting conditions provision” means a policy provision which limits or excludes benefits relating to a condition based on the fact that the condition was present before the effective date of coverage, for which any medical advice, diagnosis, care or treatment was recommended or received before such effective date. Routine follow-up care to determine whether a breast cancer has reoccurred in a person who has been previously determined to be breast cancer free shall not be considered as medical advice, diagnosis, care or treatment for purposes of this section unless evidence of breast cancer is found during or as a result of such follow-up. Genetic information shall not be treated as a condition in the absence of a diagnosis of the condition related to such information. Pregnancy shall not be considered a preexisting condition.

(4) “Qualifying coverage” means (A) any group health insurance plan, insurance arrangement or self-insured plan, (B) Medicare or Medicaid, or (C) an individual health insurance plan that provides benefits which are actuarially equivalent to or exceeding the benefits provided under the small employer health care plan, as defined in subdivision (12) of section 38a-564, whether issued in this state or any other state.

(5) “Applicable waiting period” means the period of time imposed by the group policyholder or contractholder before an individual is eligible for participating in the group policy or contract.

(b) (1) No group health insurance plan or insurance arrangement shall impose a preexisting conditions provision that excludes coverage for (A) individuals eighteen years of age and younger, or (B) a period beyond twelve months following the insured’s effective date of coverage. Any preexisting conditions provision shall only relate to conditions, whether physical or mental, for which medical advice, diagnosis or care or treatment was recommended or received during the six months immediately preceding the effective date of coverage.

(2) No individual health insurance plan or insurance arrangement shall impose a preexisting conditions provision that excludes coverage for (A) individuals eighteen years of age and younger, or (B) a period beyond twelve months following the insured’s effective date of coverage. Any preexisting conditions provision shall only relate to conditions, whether physical or mental, for which medical advice, diagnosis or care or treatment was recommended or received during the twelve months immediately preceding the effective date of coverage.

(3) No insurance company, fraternal benefit society, hospital service corporation, medical service corporation or health care center shall refuse to issue an individual health insurance plan or insurance arrangement to individuals eighteen years of age and younger solely on the basis that an individual has a preexisting condition.

(c) All health insurance plans and insurance arrangements shall provide coverage, under the terms and conditions of their policies or contracts, for the preexisting conditions of any newly insured individual who was previously covered for such preexisting condition under the terms of the individual’s preceding qualifying coverage, provided the preceding coverage was continuous to a date less than one hundred twenty days prior to the effective date of the new coverage, exclusive of any applicable waiting period, except in the case of a newly insured group member whose previous coverage was terminated due to an involuntary loss of employment, the preceding coverage must have been continuous to a date not more than one hundred fifty days prior to the effective date of the new coverage, exclusive of any applicable waiting period, provided such newly insured group member or dependent applies for such succeeding coverage within thirty days of the member’s or dependent’s initial eligibility.

(d) With respect to a newly insured individual who was previously covered under qualifying coverage, but who was not covered under such qualifying coverage for a preexisting condition, as defined under the new health insurance plan or arrangement, such plan or arrangement shall credit the time such individual was previously covered by qualifying coverage to the exclusion period of the preexisting condition provision, provided the preceding coverage was continuous to a date less than one hundred twenty days prior to the effective date of the new coverage, exclusive of any applicable waiting period under such plan, except in the case of a newly insured group member whose preceding coverage was terminated due to an involuntary loss of employment, the preceding coverage must have been continuous to a date not more than one hundred fifty days prior to the effective date of the new coverage, exclusive of any applicable waiting period, provided such newly insured group member or dependent applies for such succeeding coverage within thirty days of the member’s or dependent’s initial eligibility.

(e) Each insurance company, fraternal benefit society, hospital service corporation, medical service corporation or health care center which issues in this state group health insurance subject to Section 2701 of the Public Health Service Act, as set forth in the Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191) (HIPAA), as amended from time to time, shall comply with the provisions of said section with respect to such group health insurance, except that the longer period of days specified in subsections (c) and (d) of this section shall apply to the extent excepted from preemption in Section 2723(B)(2)(iii) of said Public Health Service Act.

(f) The provisions of this section shall apply to every health insurance plan or insurance arrangement issued, renewed or continued in this state on or after October 1, 1993. For purposes of this section, the date a plan or arrangement is continued shall be the anniversary date of the issuance of the plan or arrangement. The provisions of subsection (e) of this section shall apply on and after the dates specified in Sections 2747 and 2792 of the Public Health Service Act as set forth in HIPAA.

(g) Notwithstanding the provisions of subsection (a) of this section, a short-term health insurance policy issued on a nonrenewable basis for six months or less which imposes a preexisting conditions provision shall be subject to the following conditions: (1) No such preexisting conditions provision shall exclude coverage beyond twelve months following the insured’s effective date of coverage; (2) such preexisting conditions provision may only relate to conditions, whether physical or mental, for which medical advice, diagnosis, care or treatment was recommended or received during the twenty-four months immediately preceding the effective date of coverage; and (3) any policy, application or sales brochure issued for such short-term health insurance policy that imposes such preexisting conditions provision shall disclose in a conspicuous manner in not less than fourteen-point bold face type the following statement:

“THIS POLICY EXCLUDES COVERAGE FOR CONDITIONS FOR WHICH MEDICAL ADVICE, DIAGNOSIS, CARE OR TREATMENT WAS RECOMMENDED OR RECEIVED DURING THE TWENTY-FOUR MONTHS IMMEDIATELY PRECEDING THE EFFECTIVE DATE OF COVERAGE.”

In the event an insurer or health care center issues two consecutive short-term health insurance policies on a nonrenewable basis for six months or less which imposes a preexisting conditions provision to the same individual, the insurer or health care center shall reduce the preexisting conditions exclusion period in the second policy by the period of time such individual was covered under the first policy. If the same insurer or health care center issues a third or subsequent such short-term health insurance policy to the same individual, such insurer or health care center shall reduce the preexisting conditions exclusion period in the third or subsequent policy by the cumulative time covered under the prior policies. Nothing in this section shall be construed to require such short-term health insurance policy to be issued on a guaranteed issue or guaranteed renewable basis.

(h) The commissioner may adopt regulations, in accordance with the provisions of chapter 54, to enforce the provisions of HIPAA and this section concerning preexisting conditions and portability.

(P.A. 93-345, S. 3; P.A. 96-87, S. 1–3; 96-177, S. 5; June 18 Sp. Sess. P.A. 97-8, S. 65, 88; P.A. 98-27, S. 14; P.A. 00-121; P.A. 02-24, S. 5; P.A. 07-113, S. 3; P.A. 08-110, S. 2; P.A. 11-58, S. 41.)

History: P.A. 96-87 amended Subsec. (a) and added Subsec. (f) to exempt “short-term” policies which provide the prescribed disclosures, effective May 8, 1996; P.A. 96-177 redefined “preexisting conditions provision” to specify that breast cancer check-ups are not medical advice, diagnosis, care or treatment unless evidence of breast cancer is found; June 18 Sp. Sess. P.A. 97-8 redefined “preexisting conditions provision” in Subsec. (a), amended Subsec. (b) to delete references to pregnancy, to substitute “whether physical or mental” for “manifesting themselves or” in Subdiv. (1) and to substitute “whether physical or mental, which manifest themselves” for “manifesting themselves” in Subdiv. (2), amended Subsecs. (c) and (d) to substitute “less than sixty-three days” for “not more than thirty days” and to substitute “sixty-three days” for “thirty days”, added new Subsec. (e) re compliance with the Public Health Service Act, designated former Subsecs. (e) and (f) as Subsecs. (f) and (g) respectively, amending new Subsec. (f) re application dates of Subsec. (e), and added new Subsec. (h) re regulations to enforce HIPAA, effective July 1, 1997; P.A. 98-27 amended Subsec. (d) to substitute “time such individual” for “time such person” and substituted “such individual’s initial eligibility” for “their initial eligibility”; P.A. 00-121 amended Subsecs. (c) and (d) by amending time periods from 63 to 120 days and 90 to 150 days, amending application deadline from 63 to 30 days, and making technical changes for purposes of gender neutrality; P.A. 02-24 substituted “their” for “its” in Subsec. (c); P.A. 07-113 amended Subsec. (b)(2) to delete reference to conditions “which manifest themselves”, amended Subsec. (g) to require a short-term health insurance policy which imposes preexisting conditions provision to be subject to conditions, including a requirement for disclosure of a statement re exclusion of coverage under the policy in a conspicuous manner, to provide for a reduction in preexisting conditions exclusion period in the second, third or subsequent policy if an insurer or health care center issues two, three or more consecutive short-term health insurance policies with preexisting conditions provision to the same individual, and to require that nothing in section be construed to require short-term health insurance policy to be issued on a guaranteed issue or guaranteed renewable basis, and amended Subsec. (h) to authorize commissioner to adopt regulations to enforce provisions of section; P.A. 08-110 changed “may” to “shall” and made technical changes in Subsec. (b), effective May 27, 2008; P.A. 11-58 amended Subsec. (b) to prohibit preexisting conditions provision that excludes coverage for individuals 18 years of age and younger in Subdivs. (1) and (2), and added Subdiv. (3) prohibiting issuance refusal of an individual health insurance plan or arrangement to such individuals solely on the basis of a preexisting condition, effective July 2, 2011.

Sec. 38a-476a. Compliance with the Health Insurance Portability and Accountability Act. Guaranteed renewability. Discrimination based on health status, newborns’ and mothers’ health prohibited. Parity of mental health benefits. Disclosure of information for employers. Construction. Application. Regulations. (a) Each insurance company, fraternal benefit society, hospital service corporation, medical service corporation and health care center shall comply with sections 2742, 2743, and 2747 of the Public Health Service Act, as set forth in the Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191) (HIPAA), as amended from time to time, concerning guaranteed renewability of individual health insurance coverage and certification of coverage.

(b) Each insurance company, fraternal benefit society, hospital service corporation, medical service corporation and health care center shall comply with sections 2702, 2704, 2705 and 2712 of the Public Health Service Act, as set forth in the Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191 and 104-204) (HIPAA), as amended from time to time, concerning discrimination based on health status, newborns’ and mothers’ health, parity of mental health benefits and guaranteed renewability of coverage for employers in the group market, with respect to health insurance coverage offered in the small and large group markets as defined in said Public Health Service Act.

(c) Each insurance company, fraternal benefit society, hospital service corporation, medical service corporation and health care center shall comply with sections 2711 and 2713 of the Public Health Service Act, as set forth in the Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191) (HIPAA), as amended from time to time, concerning guaranteed availability and disclosure of information for employers with respect to health insurance coverage offered in the small group market as defined in said Public Health Service Act.

(d) No provision of the general statutes concerning a HIPAA requirement shall be construed to supersede any other provision of the general statutes except to the extent that such other provision prevents the application of a requirement of HIPAA.

(e) This section shall apply to insurance companies, fraternal benefit societies, hospital service corporations, medical service corporations and health care centers on and after the dates specified in the Public Health Service Act, as set forth in the Health Insurance Portability and Accountability Act of 1996, (P.L. 104-191 and 104-204) (HIPAA), as amended from time to time.

(f) The commissioner may adopt regulations, in accordance with the provisions of chapter 54, to implement the provisions of this section and the provisions of the Public Health Service Act, as set forth in the Health Insurance Portability and Accountability Act of 1996, as amended from time to time.

(June 18 Sp. Sess. P.A. 97-8, S. 66, 88.)

History: June 18 Sp. Sess. P.A. 97-8 effective July 1, 1997.

Sec. 38a-476b. Standards re psychotropic drug availability in health plans. Notwithstanding any provision of the general statutes or the regulations of Connecticut state agencies, no mental health care benefit provided under state law, or with state funds or to state employees may, through the use of a drug formulary, list of covered drugs or any other means: (1) Limit the availability of psychotropic drugs that are the most effective therapeutically indicated pharmaceutical treatment with the least probability of adverse side effects; or (2) require utilization of psychotropic drugs that are not the most effective therapeutically indicated pharmaceutical treatment with the least probability of adverse side effects. Nothing in this section shall be construed to limit the authority of a physician to prescribe a drug that is not the most recent pharmaceutical treatment. Nothing in this section shall be construed to prohibit differential copays among pharmaceutical treatments or to prohibit utilization review.

(P.A. 01-171, S. 17.)

Sec. 38a-476c. Policies and contracts with variable network and enrollee cost-sharing. Approval. Limitations. (a) The Insurance Commissioner shall approve any health insurance policy or contract, including, but not limited to, a policy or contract filed by a health care center, that uses variable networks and enrollee cost-sharing as set forth in subsection (b) of this section if (1) the policy or contract meets the requirements of this title, (2) the policy or contract form or amendment thereto filed with the commissioner is accompanied by a rate filing for the policy or contract and (3) the commissioner finds that the rate filing reflects a reasonable reduction in premiums or fees as compared to policies or contracts that do not use such variable networks and enrollee cost-sharing.

(b) Such policies and contracts shall be limited to policies and contracts that: (1) Offer choices among provider networks of different size; (2) offer different deductibles depending on the type of health care facility used; or (3) offer prescription drug benefits that use any combination of deductibles, coinsurance not to exceed thirty per cent or copayments, including combinations of such deductibles, coinsurance or copayments at different benefit levels.

(P.A. 05-238, S. 7.)

Sec. 38a-477. Standardized claim forms. Information necessary for filing a claim. Regulations. (a) Except where there is an agreement to the contrary between a third-party payer and the health care provider, as defined in section 19a-17b, all health care providers shall submit all third-party claims for payment on the current standard Health Care Financing Administration Fifteen Hundred (HCFA1500) health insurance claim form or its successor, or in the case of a hospital or other health care institution, a Health Care Financing Administration UB-92 health insurance claim form or its successor, or in accordance with other forms which may be prescribed by the Insurance Commissioner.

(b) For any claim submitted to an insurer on the current standard Health Care Financing Administration Fifteen Hundred health insurance claim form or its successor, if the following information is completed and received by the insurer, the claim may not be deemed to be deficient in the information needed for filing a claim for processing pursuant to subparagraph (B) of subdivision (15) of section 38a-816.

Item Number

       Item Description

1a

Insured’s identification number

2

Patient’s name

3

Patient’s birth date and sex

4

Insured’s name

10a

Patient’s condition - employment

10b

Patient’s condition - auto accident

10c

Patient’s condition - other accident

11

Insured’s policy group number (if provided on identification card)

11d

Is there another health benefit plan?

17a

Identification number of referring physician or advanced practice registered nurse (if required by insurer)

21

Diagnosis

24A

Dates of service

24B

Place of service

24D

Procedures, services or supplies

24E

Diagnosis code

24F

Charges

25

Federal tax identification number

28

Total charge

31

Signature of physician, advanced practice registered nurse or supplier with date

33

Physician’s, advanced practice registered nurse’s or supplier’s billing name, address, zip code & telephone number

(c) For any claim submitted to an insurer on the current standard Health Care Financing Administration UB-92 health insurance claim form or its successor, if the following information is completed and received by the insurer, the claim may not be deemed to be deficient in the information needed for filing a claim for processing pursuant to subparagraph (B) of subdivision (15) of section 38a-816.

Item Number

       Item Description

1

Provider name and address

5

Federal tax identification number

6

Statement covers period

12

Patient name

14

Patient’s birth date

15

Patient’s sex

17

Admission date

18

Admission hour

19

Type of admission

21

Discharge hour

42

Revenue codes

43

Revenue description

44

HCPCS/CPT4 codes

45

Service date

46

Service units

47

Total charges by revenue code

50

Payer identification

51

Provider number

58

Insured’s name

60

Patient’s identification number (policy number and/or Social Security number)

62

Insurance group number (if on identification card)

67

Principal diagnosis code

76

Admitting diagnosis code

80

Principle procedure code and date

81

Other procedures code and date

82

The identification number of the attending physician or advanced practice registered nurse

(d) The commissioner may adopt regulations, in accordance with chapter 54, to implement the provisions of this section.

(P.A. 93-109; P.A. 03-57, S. 2; P.A. 12-197, S. 41.)

History: P.A. 03-57 substituted “Health Care Financing Administration UB-92 health insurance claim form” for “UB-82” in Subsec. (a), added new Subsecs. (b) and (c) re information on HCFA1500 claim form and UB-92 claim form, respectively, redesignated existing Subsec. (b) as Subsec. (d) and made technical changes therein; P.A. 12-197 amended Subsec. (b) by adding references to advanced practice registered nurse in items 17a, 31 and 33 and amended Subsec. (c) by adding reference to advanced practice registered nurse and making a technical change in item 82.

Sec. 38a-477a. Notification by Insurance Commissioner of required benefits and policy forms. The Insurance Commissioner shall provide written or electronic notification to each insurance company, fraternal benefit society, hospital service corporation, medical service corporation, health care center or any other entity that delivers or issues for delivery, in this state, any individual or group health insurance plan (1) of any benefits required to be provided in such plan pursuant to this chapter, or of any modification to such benefits on or after October 1, 2006, at least thirty days prior to the date such benefits or modification becomes effective, and (2) instructing such company, society, corporation, center or other entity to submit to the Insurance Commissioner, prior to the date such benefits or modification becomes effective or upon the renewal date of the plan, any necessary policy forms, in accordance with the provisions of section 38a-481 or 38a-513, as applicable, that reflect such benefits or modification.

(P.A. 06-188, S. 35; P.A. 08-147, S. 6.)

History: P.A. 08-147 authorized electronic notification provided by commissioner.

Sec. 38a-477b. Postclaims underwriting prohibited unless approval granted. Application for approval of rescission, cancellation or limitation. Decision. Appeals. Regulations. (a) Unless approval is granted pursuant to subsection (b) of this section, no insurer or health care center may rescind, cancel or limit any policy of insurance, contract, evidence of coverage or certificate that provides coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469 on the basis of written information submitted on, with or omitted from an insurance application by the insured if the insurer or health care center failed to complete medical underwriting and resolve all reasonable medical questions related to the written information submitted on, with or omitted from the insurance application before issuing the policy, contract, evidence of coverage or certificate. No insurer or health care center may rescind, cancel or limit any such policy, contract, evidence of coverage or certificate more than two years after the effective date of the policy, contract, evidence of coverage or certificate.

(b) An insurer or health care center shall apply for approval of such rescission, cancellation or limitation by submitting such written information to the Insurance Commissioner on an application in such form as the commissioner prescribes. Such insurer or health care center shall provide a copy of the application for such approval to the insured or the insured’s representative. Not later than seven business days after receipt of the application for such approval, the insured or the insured’s representative shall have an opportunity to review such application and respond and submit relevant information to the commissioner with respect to such application. Not later than fifteen business days after the submission of information by the insured or the insured’s representative, the commissioner shall issue a written decision on such application. The commissioner shall only approve:

(1) Such rescission or limitation if the commissioner finds that (A) the insured or such insured’s representative submitted the written information on or with the insurance application that was fraudulent at the time such application was made, (B) the insured or such insured’s representative intentionally misrepresented information therein and such misrepresentation materially affects the risk or the hazard assumed by the insurer or health care center, or (C) the information omitted from the insurance application was intentionally omitted by the insured or such insured’s representative and such omission materially affects the risk or the hazard assumed by the insurer or health care center. Such decision shall be mailed to the insured, the insured’s representative, if any, and the insurer or health care center; and

(2) Such cancellation in accordance with the provisions set forth in the Public Health Service Act, 42 USC 300gg et seq., as amended from time to time.

(c) Notwithstanding the provisions of chapter 54, any insurer or insured aggrieved by any decision by the commissioner under subsection (b) of this section may, within thirty days after notice of the commissioner’s decision is mailed to such insurer and insured, take an appeal therefrom to the superior court for the judicial district of Hartford, which shall be accompanied by a citation to the commissioner to appear before said court. Such citation shall be signed by the same authority, and such appeal shall be returnable at the same time and served and returned in the same manner, as is required in case of a summons in a civil action. Said court may grant such relief as may be equitable.

(d) The Insurance Commissioner may adopt regulations, in accordance with chapter 54, to implement the provisions of this section.

(P.A. 07-113, S. 1; P.A. 11-58, S. 47, 69.)

History: P.A. 11-58 amended Subsec. (b) by replacing “may” with “shall only” re commissioner’s approval, designating existing provisions re submission of false information as Subdiv. (1) and amending same by changing provisions re the knowing submission of false information by an insured to the intentional misrepresentation of fraudulent information by an insured, adding Subdiv. (2) re provision governing cancellation of policy in accordance with Public Health Service Act, and making conforming and technical changes, effective July 1, 2011.

Sec. 38a-477c. Disclosure of state and federal medical loss ratio with each health insurance application. An insurer or health care center shall include a written notice with each application for individual or group health insurance coverage that discloses such insurer’s or health care center’s state medical loss ratio and federal medical loss ratio, as both terms are defined in section 38a-478l, as reported in the last Consumer Report Card on Health Insurance Carriers in Connecticut, to an applicant at the time of application for coverage.

(P.A. 09-46, S. 2; P.A. 11-58, S. 50.)

History: P.A. 11-58 added federal medical loss ratio to information disclosed with application for health insurance coverage and made conforming changes, effective January 1, 2012.

PART Ia

HEALTH INSURANCE: MANAGED CARE

Sec. 38a-478. Definitions. As used in this section, sections 38a-478a to 38a-478o, inclusive, and subsection (a) of section 38a-478s:

(1) “Commissioner” means the Insurance Commissioner.

(2) “Covered benefit” or “benefit” means a health care service to which an enrollee is entitled under the terms of a health benefit plan.

(3) “Enrollee” means a person who has contracted for or who participates in a managed care plan for such person or such person’s eligible dependents.

(4) “Health care services” means services for the diagnosis, prevention, treatment, cure or relief of a health condition, illness, injury or disease.

(5) “Managed care organization” means an insurer, health care center, hospital or medical service corporation or other organization delivering, issuing for delivery, renewing, amending or continuing any individual or group health managed care plan in this state.

(6) “Managed care plan” means a product offered by a managed care organization that provides for the financing or delivery of health care services to persons enrolled in the plan through: (A) Arrangements with selected providers to furnish health care services; (B) explicit standards for the selection of participating providers; (C) financial incentives for enrollees to use the participating providers and procedures provided for by the plan; or (D) arrangements that share risks with providers, provided the organization offering a plan described under subparagraph (A), (B), (C) or (D) of this subdivision is licensed by the Insurance Department pursuant to chapter 698, 698a or 700 and the plan includes utilization review, as defined in section 38a-591a.

(7) “Preferred provider network” has the same meaning as provided in section 38a-479aa.

(8) “Provider” or “health care provider” means a person licensed to provide health care services under chapters 370 to 373, inclusive, 375 to 383c, inclusive, 384a to 384c, inclusive, or chapter 400j.

(9) “Utilization review” has the same meaning as provided in section 38a-591a.

(10) “Utilization review company” has the same meaning as provided in section 38a-591a.

(P.A. 97-99, S. 1; P.A. 03-169, S. 10; P.A. 04-125, S. 2; P.A. 05-94, S. 5; P.A. 09-49, S. 1; P.A. 11-58, S. 67.)

History: P.A. 03-169 added Subdivs. (6) to (8), defining “preferred provider network”, “utilization review” and “utilization review company”; P.A. 04-125 redefined “provider” in Subdiv. (4) to reference “chapter 383c”; P.A. 05-94 redefined “enrollee” in Subdiv. (5) to add “Except as provided in sections 38a-478m and 38a-478n”, effective July 1, 2005; P.A. 09-49 defined “adverse determination” in new Subdiv. (1), “covered benefit” and “health care services” in new Subdivs. (3) and (5) and “review entity” in new Subdiv. (10), repositioned definitions of “enrollee” from former Subdiv. (5) to new Subdiv. (4) and “preferred provider network” from former Subdiv. (6) to new Subdiv. (8), redesignated existing Subdivs. (1) to (4), (7) and (8) as Subdivs. (2), (6), (7), (9), (11) and (12), and made conforming and technical changes; P.A. 11-58 deleted former Subdivs. (1) and (10) re definitions of “adverse determination” and “review entity”, replaced references to Sec. 38a-226 with references to Sec. 38a-591a and made conforming and technical changes, effective July 1, 2011.

Sec. 38a-478a. Commissioner’s report to the Governor and the General Assembly. On March first annually, the Insurance Commissioner shall submit a report to the Governor and to the joint standing committees of the General Assembly having cognizance of matters relating to public health and insurance, concerning the commissioner’s responsibilities under the provisions of sections 38a-478 to 38a-478u, inclusive, 38a-479aa, 38a-591a to 38a-591h, inclusive, and 38a-993. The report shall include: (1) A summary of the quality assurance plans submitted by managed care organizations pursuant to section 38a-478c along with suggested changes to improve such plans; (2) suggested modifications to the consumer report card developed under the provisions of section 38a-478l; (3) a summary of the commissioner’s procedures and activities in conducting market conduct examinations of utilization review companies and preferred provider networks, including, but not limited to: (A) The number of desk and field audits completed during the previous calendar year; (B) a summary of findings of the desk and field audits, including any recommendations made for improvements or modifications; (C) a description of complaints concerning managed care companies, and any preferred provider network that provides services to enrollees on behalf of the managed care organization, including a summary and analysis of any trends or similarities found in the managed care complaints filed by enrollees; (4) a summary of the complaints concerning managed care organizations received by the Insurance Department’s Consumer Affairs Division and the commissioner under section 38a-591g, including a summary and analysis of any trends or similarities found in the complaints received; (5) a summary of any violations the commissioner has found against any managed care organization or any preferred provider network that provides services to enrollees on behalf of the managed care organization; and (6) a summary of the issues discussed related to health care or managed care organizations at the Insurance Department’s quarterly forums throughout the state.

(P.A. 97-99, S. 2; June 18 Sp. Sess. P.A. 97-8, S. 57, 88; P.A. 99-284, S. 51, 60; P.A. 00-196, S. 22; June Sp. Sess. P.A. 01-4, S. 23; P.A. 03-169, S. 11; P.A. 11-58, S. 70.)

History: June 18 Sp. Sess. P.A. 97-8 changed reporting date from January 15, 1999, to March 1, 1999, and in Subdiv. (3)(C) changed “complaints” to “managed care complaints”, effective July 1, 1997; P.A. 99-284 deleted obsolete reference to Sec. 38a-514a, effective January 1, 2000; P.A. 00-196 made a technical change; June Sp. Sess. P.A. 01-4 replaced reference to Sec. 19a-647 with reference to Sec. 38a-479aa; P.A. 03-169 added provisions re preferred provider networks in Subdivs. (3) and (5); P.A. 11-58 replaced references to Secs. 38a-226 to 38a-226d and 38a-478n with “sections 38a-591a to 38a-591h, inclusive,” and “section 38a-591g”, respectively, added “concerning managed care organizations” in Subdiv. (4), and made technical changes, effective July 1, 2011.

Sec. 38a-478b. Penalty for managed care organization’s failure to file data and reports. Commissioner’s report to the Governor and the General Assembly on organizations that fail to file data and reports. (a) Each managed care organization, as defined in section 38a-478, that fails to file the data, reports or information required by sections 38a-478 to 38a-478u, inclusive, 38a-479aa, 38a-591a to 38a-591h, inclusive, and 38a-993 shall pay a late fee of one hundred dollars per day for each day from the due date of such data, reports or information to the date of filing. Each managed care organization that files incomplete data, reports or information shall be so informed by the commissioner, shall be given a date by which to remedy such incomplete filing and shall pay said late fee commencing from the new due date.

(b) On June first annually, the commissioner shall submit to the Governor and to the joint standing committees of the General Assembly having cognizance of matters relating to public health and insurance, a list of those managed care organizations that have failed to file any data, report or information required by sections 38a-478 to 38a-478u, inclusive, 38a-479aa, 38a-591a to 38a-591h, inclusive, and 38a-993.

(P.A. 97-99, S. 3; P.A. 99-284, S. 52, 60; P.A. 00-196, S. 23; June Sp. Sess. P.A. 01-4, S. 24; P.A. 11-58, S. 71.)

History: P.A. 99-284 deleted obsolete references to Sec. 38a-514a, effective January 1, 2000; P.A. 00-196 made a technical change in Subsec. (b); June Sp. Sess. P.A. 01-4 replaced references to Sec. 19a-647 with references to Sec. 38a-479aa; P.A. 11-58 replaced references to Secs. 38a-226 to 38a-226d with “sections 38a-591a to 38a-591h, inclusive,” and made technical changes, effective July 1, 2011.

Sec. 38a-478c. Managed care organization’s report to the commissioner: Data, reports and information required. (a) On or before May first of each year, each managed care organization shall submit to the commissioner:

(1) A report on its quality assurance plan that includes, but is not limited to, information on complaints related to providers and quality of care, on decisions related to patient requests for coverage and on prior authorization statistics. Statistical information shall be submitted in a manner permitting comparison across plans and shall include, but not be limited to: (A) The ratio of the number of complaints received to the number of enrollees; (B) a summary of the complaints received related to providers and delivery of care or services and the action taken on the complaint; (C) the ratio of the number of prior authorizations denied to the number of prior authorizations requested; (D) the number of utilization review determinations made by or on behalf of a managed care organization not to certify an admission, service, procedure or extension of stay, and the denials upheld and reversed on appeal within the managed care organization’s utilization review procedure; (E) the percentage of those employers or groups that renew their contracts within the previous twelve months; and (F) notwithstanding the provisions of this subsection, on or before July first of each year, all data required by the National Committee for Quality Assurance (NCQA) for its Health Plan Employer Data and Information Set (HEDIS). If an organization does not provide information for the National Committee for Quality Assurance for its Health Plan Employer Data and Information Set, then it shall provide such other equivalent data as the commissioner may require by regulations adopted in accordance with the provisions of chapter 54. The commissioner shall find that the requirements of this subdivision have been met if the managed care plan has received a one-year or higher level of accreditation by the National Committee for Quality Assurance and has submitted the Health Plan Employee Data Information Set data required by subparagraph (F) of this subdivision;

(2) A model contract that contains the provisions currently in force in contracts between the managed care organization and preferred provider networks in this state, and the managed care organization and participating providers in this state and, upon the commissioner’s request, a copy of any individual contracts between such parties, provided the contract may withhold or redact proprietary fee schedule information;

(3) A written statement of the types of financial arrangements or contractual provisions that the managed care organization has with hospitals, utilization review companies, physicians, preferred provider networks and any other health care providers including, but not limited to, compensation based on a fee-for-service arrangement, a risk-sharing arrangement or a capitated risk arrangement;

(4) Such information as the commissioner deems necessary to complete the consumer report card required pursuant to section 38a-478l. Such information may include, but need not be limited to: (A) The organization’s characteristics, including its model, its profit or nonprofit status, its address and telephone number, the length of time it has been licensed in this and any other state, its number of enrollees and whether it has received any national or regional accreditation; (B) a summary of the information required by subdivision (3) of this section, including any change in a plan’s rates over the prior three years, its state medical loss ratio and its federal medical loss ratio, as both terms are defined in section 38a-478l, how it compensates health care providers and its premium level; (C) a description of services, the number of primary care physicians and specialists, the number and nature of participating preferred provider networks and the distribution and number of hospitals, by county; (D) utilization review information, including the name or source of any established medical protocols and the utilization review standards; (E) medical management information, including the provider-to-patient ratio by primary care provider and specialty care provider, the percentage of primary and specialty care providers who are board certified, and how the medical protocols incorporate input as required in section 38a-478e; (F) the quality assurance information required to be submitted under the provisions of subdivision (1) of subsection (a) of this section; (G) the status of the organization’s compliance with the reporting requirements of this section; (H) whether the organization markets to individuals and Medicare recipients; (I) the number of hospital days per thousand enrollees; and (J) the average length of hospital stays for specific procedures, as may be requested by the commissioner;

(5) A summary of the procedures used by managed care organizations to credential providers; and

(6) A report on claims denial data for lives covered in the state for the prior calendar year, in a format prescribed by the commissioner, that includes: (A) The total number of claims received; (B) the total number of claims denied; (C) the total number of denials that were appealed; (D) the total number of denials that were reversed upon appeal; (E) (i) the reasons for the denials, including, but not limited to, “not a covered benefit”, “not medically necessary” and “not an eligible enrollee”, (ii) the total number of times each reason was used, and (iii) the percentage of the total number of denials each reason was used; and (F) other information the commissioner deems necessary.

(b) The information required pursuant to subsection (a) of this section shall be consistent with the data required by the National Committee for Quality Assurance (NCQA) for its Health Plan Employer Data and Information Set (HEDIS).

(c) The commissioner may accept electronic filing for any of the requirements under this section.

(d) No managed care organization shall be liable for a claim arising out of the submission of any information concerning complaints concerning providers, provided the managed care organization submitted the information in good faith.

(e) The information required under subdivision (6) of subsection (a) of this section shall be posted on the Insurance Department’s Internet web site.

(P.A. 97-99, S. 4; P.A. 98-27, S. 19; P.A. 03-169, S. 12; P.A. 09-46, S. 3; P.A. 10-5, S. 16; 10-19, S. 1; P.A. 11-58, S. 51.)

History: P.A. 98-27 amended Subpara. (a)(1)(F) to add “Notwithstanding the provisions of this subsection, on or before July 1, 1998, and annually thereafter” re required data; P.A. 03-169 amended Subsec. (a) to reword Subdiv. (1)(D) re utilization review determinations, to add in Subdivs. (2) and (3) reference to preferred provider networks, to substitute “required” for “he is required to develop and distribute” in Subdiv. (4) and to add “the number and nature of participating preferred provider networks” in Subpara. (C), and make conforming changes; P.A. 09-46 amended Subsec. (a) to make a technical change and, in Subdiv. (4)(B), to replace provision re percentage of total premium revenues with definition of medical loss ratio in Sec. 38a-478l(b); P.A. 10-5 made a technical change in Subsec. (a)(1), effective May 5, 2010; P.A. 10-19 made a technical change in Subsec. (a)(1), added Subsec. (a)(6) re report on claims denial data and added Subsec. (e) re posting of data on Insurance Department’s web site, effective July 1, 2010; P.A. 11-58 amended Subsec. (a) to add federal medical loss ratio to information provided to commissioner to complete consumer report card in Subdiv. (4) and to make technical changes, effective January 1, 2012.

Sec. 38a-478d. List of providers required. Notification to enrollee of termination or withdrawal of enrollee’s primary care provider. For any contract delivered, issued for delivery, renewed, amended or continued in this state, each managed care organization shall:

(1) Provide at least annually to each enrollee a listing of all providers available under the provisions of the enrollee’s enrollment agreement, in writing or through the Internet at the option of the enrollee;

(2) Include, under a separate category or heading, participating advanced practice registered nurses in the listing of providers specified under subdivision (1) of this section; and

(3) For a managed care plan that requires the selection of a primary care provider:

(A) Allow an enrollee to designate a participating, in-network physician or a participating, in-network advanced practice registered nurse as such enrollee’s primary care provider; and

(B) Provide notification, as soon as possible, to each such enrollee upon the termination or withdrawal of the enrollee’s primary care provider.

(P.A. 97-99, S. 5; P.A. 07-18, S. 1; P.A. 11-199, S. 1.)

History: P.A. 07-18 amended Subdiv. (1) to require that list of providers be given in writing or through the Internet at the option of enrollee and amended Subdiv. (2) to limit notification to enrollee in a managed care plan that requires selection of a primary care physician; P.A. 11-199 substantially revised section to require managed care organizations to include in their provider listings advanced practice registered nurses under a separate category or heading and to allow enrollees to designate a participating, in-network physician or a participating, in-network advanced practice registered nurse as such enrollee’s primary care provider.

Sec. 38a-478e. Medical protocols. Procedure prior to change. Physician input. Notification of change. (a) Each managed care organization shall, prior to implementing new medical protocols or substantially or materially altering existing medical protocols, obtain input from physicians actively practicing in Connecticut and practicing in the relevant specialty areas. The managed care organization shall also seek input from physicians who are not employees of or consultants, other than to the extent a person is an employee or consultant solely for the purposes of this subsection, to the managed care organization provided the input is not unreasonably withheld. The managed care organization shall obtain the input in a manner permitting verification by the commissioner and shall document the process by which it obtained the input. For the purpose of this section, “medical protocols” shall include, but not be limited to, drug formularies or lists of covered drugs.

(b) Each managed care organization shall (1) make available, upon the request of a participating provider, its medical protocols for examination during regular business hours at the principal Connecticut headquarters of the managed care organization, and (2) if a managed care organization denies a treatment, service or procedure, the organization shall furnish, upon the request of a participating provider, a copy of the relevant medical protocol to the participating provider, along with an explanation of the denial at the time the denial is made.

(P.A. 97-99, S. 6; P.A. 00-216, S. 7, 28.)

History: P.A. 00-216 amended Subsec. (a) by making a technical change and adding provision defining “medical protocols” to include drug formularies or lists of covered drugs, effective July 1, 2000.

Sec. 38a-478f. Provider profile development requirements. Each managed care organization, in developing provider profiles or otherwise measuring health care provider performance, shall: (1) Make allowances for the severity of illness or condition of the patient mix; (2) make allowances for patients with multiple illnesses or conditions; (3) make available to the commissioner documentation of how the managed care organization makes such allowances; and (4) inform enrollees and participating providers, upon request, how the managed care organization considers patient mix when profiling or evaluating providers.

(P.A. 97-99, S. 7.)

Sec. 38a-478g. Managed care contract requirements. Plan description requirements. (a) Each managed care contract delivered, issued for delivery, renewed, amended or continued in this state shall be in writing and a copy thereof furnished to the group contract holder or individual contract holder, as appropriate. Each such contract shall contain the following provisions: (1) Name and address of the managed care organization; (2) eligibility requirements; (3) a statement of copayments, deductibles or other out-of-pocket expenses the enrollee must pay; (4) a statement of the nature of the health care services, benefits or coverages to be furnished and the period during which they will be furnished and, if there are any services, benefits or coverages to be excepted, a detailed statement of such exceptions; (5) a statement of terms and conditions upon which the contract may be cancelled or otherwise terminated at the option of either party; (6) claims procedures; (7) enrollee grievance procedures; (8) continuation of coverage; (9) conversion; (10) extension of benefits, if any; (11) subrogation, if any; (12) description of the service area, and out-of-area benefits and services, if any; (13) a statement of the amount the enrollee or others on his behalf must pay to the managed care organization and the manner in which such amount is payable; (14) a statement that the contract includes the endorsement thereon and attached papers, if any, and contains the entire contract; (15) a statement that no statement by the enrollee in his application for a contract shall void the contract or be used in any legal proceeding thereunder, unless such application or an exact copy thereof is included in or attached to such contract; and (16) a statement of the grace period for making any payment due under the contract, which shall not be less than ten days. The commissioner may waive the requirements of this subsection for any managed care organization subject to the provisions of section 38a-182.

(b) Each managed care organization shall provide every enrollee with a plan description. The plan description shall be in plain language as commonly used by the enrollees and consistent with chapter 699a. The plan description shall be made available to each enrollee and potential enrollee prior to the enrollee’s entering into the contract and during any open enrollment period. The plan description shall not contain provisions or statements that are inconsistent with the plan’s medical protocols. The plan description shall contain:

(1) A clear summary of the provisions set forth in subdivisions (1) to (12), inclusive, of subsection (a) of this section, subdivision (3) of subsection (a) of section 38a-478c and sections 38a-478j to 38a-478l, inclusive;

(2) A statement of the number of managed care organization’s utilization review determinations not to certify an admission, service, procedure or extension of stay, and the denials upheld and reversed on appeal within the managed care organization’s utilization review procedure;

(3) A description of emergency services, the appropriate use of emergency services, including the use of E 9-1-1 telephone systems, any cost sharing applicable to emergency services and the location of emergency departments and other settings in which participating physicians and hospitals provide emergency services and post stabilization care;

(4) Coverage of the plans, including exclusions of specific conditions, ailments or disorders;

(5) The use of drug formularies or any limits on the availability of prescription drugs and the procedure for obtaining information on the availability of specific drugs covered;

(6) The number, types and specialties and geographic distribution of direct health care providers;

(7) Participating and nonparticipating provider reimbursement procedure;

(8) Preauthorization and utilization review requirements and procedures, internal grievance procedures and internal and external complaint procedures;

(9) The state medical loss ratio and the federal medical loss ratio, as both terms are defined in section 38a-478l, as reported in the last Consumer Report Card on Health Insurance Carriers in Connecticut;

(10) The plan’s for-profit, nonprofit incorporation and ownership status;

(11) Telephone numbers for obtaining further information, including the procedure for enrollees to contact the organization concerning coverage and benefits, claims grievance and complaint procedures after normal business hours;

(12) How notification is provided to an enrollee when the plan is no longer contracting with an enrollee’s primary care provider;

(13) The procedures for obtaining referrals to specialists or for consulting a physician other than the primary care physician;

(14) The status of the National Committee for Quality Assurance (NCQA) accreditation;

(15) Enrollee satisfaction information; and

(16) Procedures for protecting the confidentially of medical records and other patient information.

(P.A. 97-99, S. 8; June 18 Sp. Sess. P.A. 97-8, S. 58, 88; P.A. 09-46, S. 4; P.A. 11-58, S. 52; P.A. 12-145, S. 10.)

History: June 18 Sp. Sess. P.A. 97-8 amended Subsec. (a)(4) by deleting requirement of conformance to federal Health Maintenance Organization Act and (a)(16) by deleting reference to filing and amended Subsec. (b)(5) by adding provision re procedure for obtaining information on the availability of specific drugs, effective July 1, 1997; P.A. 09-46 amended Subsec. (a) to make a technical change and amended Subsec. (b)(9) to replace provision re percentage of total premium revenue with definition of medical loss ratio in Sec. 38a-478l(b) and provision re report in last consumer report card; P.A. 11-58 amended Subsec. (b)(9) to add federal medical loss ratio to information contained in plan description and make conforming changes, effective January 1, 2012; P.A. 12-145 made a technical change in Subsec. (b)(3), effective June 15, 2012.

Sec. 38a-478h. Removal of providers. Notice requirements. Retaliatory action prohibited. (a) Each contract delivered, issued for delivery, renewed, amended or continued in this state between a managed care organization and a participating provider shall require the provider to give at least sixty days’ advance written notice to the managed care organization and shall require the managed care organization to give at least sixty days’ advance written notice to the provider in order to withdraw from or terminate the agreement.

(b) The provisions of this section shall not apply: (1) When lack of such notice is necessary for the health or safety of the enrollees; (2) when a provider has entered into a contract with a managed care organization that is found to be based on fraud or material misrepresentation; or (3) when a provider engages in any fraudulent activity related to the terms of his contract with the managed care organization.

(c) No managed care organization shall take or threaten to take any action against any provider in retaliation for such provider’s assistance to an enrollee under the provisions of section 38a-591g.

(P.A. 97-99, S. 9; P.A. 11-58, S. 72.)

History: P.A. 11-58 made a technical change in Subsec. (a) and replaced references to Secs. 38a-226c(e) and 38a-478n with “section 38a-591g” in Subsec. (c), effective July 1, 2011.

Sec. 38a-478i. Limitation on enrollee rights prohibited. No contract delivered, issued for delivery, renewed, amended or continued in this state between a managed care organization and a participating provider shall prohibit or limit any cause of action or contract rights an enrollee otherwise has.

(P.A. 97-99, S. 10; P.A. 12-145, S. 41.)

History: P.A. 12-145 deleted “on and after October 1, 1997,”, effective June 15, 2012.

Sec. 38a-478j. Coinsurance payments based on negotiated discounts. Each managed care plan that requires a percentage coinsurance payment by the insured shall calculate the insured’s coinsurance payment on the lesser of the provider’s or vendor’s charges for the goods or services or the amount payable by the managed care organization for such goods or services, except as otherwise required by the laws of a foreign state when applicable to providers, vendors or patients in such foreign state.

(P.A. 97-99, S. 11; June 18 Sp. Sess. P.A. 97-8, S. 59, 88.)

History: June 18 Sp Sess. P.A. 97-8 added exception re laws of a foreign state, effective July 1, 1997.

Sec. 38a-478k. Gag clauses prohibited. (a) No contract delivered, issued for delivery, renewed, amended or continued in this state between a managed care organization and a participating provider shall prohibit the provider from discussing with an enrollee any treatment options and services available in or out of network, including experimental treatments.

(b) No contract delivered, issued for delivery, renewed, amended or continued in this state between a managed care organization and a participating provider shall prohibit the provider from disclosing, to an enrollee who inquires, the method the managed care organization uses to compensate the provider.

(P.A. 97-99, S. 12; P.A. 12-145, S. 42.)

History: P.A. 12-145 deleted “on and after October 1, 1997,”, effective June 15, 2012.

Sec. 38a-478l. Consumer report card required. Content. (a) Not later than October fifteenth of each year, the Insurance Commissioner, after consultation with the Commissioner of Public Health, shall develop and distribute a consumer report card on all managed care organizations. The commissioner shall develop the consumer report card in a manner permitting consumer comparison across organizations.

(b) (1) The consumer report card shall be known as the “Consumer Report Card on Health Insurance Carriers in Connecticut” and shall include (A) all health care centers licensed pursuant to chapter 698a, (B) the fifteen largest licensed health insurers that use provider networks and that are not included in subparagraph (A) of this subdivision, (C) the state medical loss ratio of each such health care center or licensed health insurer, (D) the federal medical loss ratio of each such health care center or licensed health insurer, (E) the information required under subdivision (6) of subsection (a) of section 38a-478c, and (F) information concerning mental health services, as specified in subsection (c) of this section. The insurers selected pursuant to subparagraph (B) of this subdivision shall be selected on the basis of Connecticut direct written health premiums from such network plans.

(2) For the purposes of this section and sections 38a-477c, 38a-478c and 38a-478g:

(A) “State medical loss ratio” means the ratio of incurred claims to earned premiums for the prior calendar year for managed care plans issued in the state. Claims shall be limited to medical expenses for services and supplies provided to enrollees and shall not include expenses for stop loss coverage, reinsurance, enrollee educational programs or other cost containment programs or features;

(B) “Federal medical loss ratio” has the same meaning as provided in, and shall be calculated in accordance with, the Patient Protection and Affordable Care Act, P.L. 111-148, as amended from time to time, and regulations adopted thereunder.

(c) With respect to mental health services, the consumer report card shall include information or measures with respect to the percentage of enrollees receiving mental health services, utilization of mental health and chemical dependence services, inpatient and outpatient admissions, discharge rates and average lengths of stay. Such data shall be collected in a manner consistent with the National Committee for Quality Assurance Health Plan Employer Data and Information Set (HEDIS) measures.

(d) The commissioner shall test market a draft of the consumer report card prior to its publication and distribution. As a result of such test marketing, the commissioner may make any necessary modification to its form or substance. The Insurance Department shall prominently display a link to the consumer report card on the department’s Internet web site.

(P.A. 97-99, S. 13; P.A. 06-188, S. 34; P.A. 07-217, S. 156; P.A. 09-46, S. 1; P.A. 10-19, S. 2; P.A. 11-58, S. 49.)

History: P.A. 06-188 added Subsec. (b)(3) re information concerning mental health services specified in new Subsec. (c), added new Subsec. (c) to require inclusion of specific mental health related information in consumer report card and redesignated existing Subsec. (c) as Subsec. (d); P.A. 07-217 made a technical change in Subsec. (c), effective July 12, 2007; P.A. 09-46 amended Subsec. (a) to replace provision re March 15 annual deadline with provision re October 15 annual deadline, amended Subsec. (b) to specify name by which consumer report card shall be known, define “medical loss ratio” and add same to list of information included in consumer report card, and amended Subsec. (d) to require Insurance Department to prominently display a link to consumer report card on its web site; P.A. 10-19 amended Subsec. (b) to add new Subdiv. (4) re information required under Sec. 38a-478c(a)(6) and redesignate existing Subdiv. (4) as Subdiv. (5), effective January 1, 2011; P.A. 11-58 amended Subsec. (b) to add requirement to include federal medical loss ratio in consumer report card, add definition of federal medical loss ratio and make conforming and technical changes, effective January 1, 2012.

Secs. 38a-478m and 38a-478n. Internal grievance procedure; notice re procedure and final resolution; penalties; fines allocated to Office of the Healthcare Advocate. Exhaustion of internal appeal mechanisms; external appeal to commissioner; applicability to health insurers, managed care organizations and utilization review companies; fees; preliminary review; full review; public outreach program; expedited external appeal; requirements for and approval of independent review entities; filing of report. Sections 38a-478m and 38a-478n are repealed, effective July 1, 2011.

(P.A. 97-99, S. 14, 20; June 18 Sp. Sess. P.A. 97-8, S. 60, 88; P.A. 99-284, S. 14, 35, 60; P.A. 03-278, S. 94; P.A. 04-157, S. 1; P.A. 05-29, s. 1; 05-94, S. 2, 3; 05-97, S. 1; 05-102, S. 1, 5; P.A. 06-54, s. 4; P.A. 07-75, S. 3; P.A. 08-147, S. 7; P.A. 09-49, S. 2; P.A. 11-58, S. 89.)

Sec. 38a-478o. Confidentiality and antidiscrimination procedures required. (a) Each managed care organization shall conform to all applicable state and federal antidiscrimination and confidentiality statutes, shall ensure that the confidentiality of specified enrollee patient information and records in its custody is protected, and shall have written confidentiality policies and procedures.

(b) No managed care organization shall sell, for any commercial purpose the names of its enrollees or any identifying information concerning enrollees.

(P.A. 97-99, S. 21; P.A. 98-27, S. 15.)

History: P.A. 98-27 amended Subsec. (a) to substitute “its” for “their”.

Sec. 38a-478p. Expedited utilization review. Standardized process required. Section 38a-478p is repealed, effective July 1, 2011.

(P.A. 97-99, S. 22, 32; P.A. 11-58, S. 89.)

Sec. 38a-478q. Use of laboratories covered by plan required. Each provider, as defined in section 38a-478, in utilizing laboratories or testing facilities for enrollees in managed care plans that provide coverage for laboratories and testing facilities, shall utilize laboratories or testing facilities covered by the enrollee’s managed care plan or notify the enrollee if the provider intends to utilize a laboratory or testing facility not covered by the plan.

(P.A. 97-99, S. 25.)

Sec. 38a-478r. Emergency rooms. Prudent layperson standard. Presenting symptoms or final diagnosis as basis for coverage. (a) Each provider, as defined in section 38a-478, shall code for the presenting symptoms of all emergency claims and each hospital shall record such code for such claims on locator 76 on the UB92 form or its successor.

(b) The presenting symptoms, as coded by the provider and recorded by the hospital on the UB92 form or its successor, or the final diagnosis, whichever reasonably indicates an emergency medical condition, shall be the basis for reimbursement or coverage, provided such symptoms reasonably indicated an emergency medical condition.

(c) For the purposes of this section, in accordance with the National Committee for Quality Assurance, an emergency medical condition is a condition such that a prudent lay-person, acting reasonably, would have believed that emergency medical treatment is needed.

(d) The Insurance Commissioner may develop and disseminate to hospitals in this state a claims form system that will ensure that all hospitals consistently code for the presenting and diagnosis symptoms on all emergency claims.

(P.A. 97-99, S. 26; June 18 Sp. Sess. P.A. 97-8, S. 61, 88; P.A. 11-58, S. 73.)

History: June 18 Sp. Sess. P.A. 97-8 amended Subsec. (b) to add provision re “the final diagnosis, whichever reasonably indicates an emergency medical condition,” effective July 1, 1997; P.A. 11-58 amended Subsec. (d) to delete provision re consultation with working group convened pursuant to Sec. 38a-478p, effective July 1, 2011.

Sec. 38a-478s. Nonapplicability to self-insured employee welfare benefit plans and workers’ compensation plans. (a) Nothing in sections 38a-478 to 38a-478o, inclusive, sections 38a-591a to 38a-591h, inclusive, or section 38a-591n shall be construed to apply to the arrangements of managed care organizations or health insurers offered to individuals covered under self-insured employee welfare benefit plans established pursuant to the federal Employee Retirement Income Security Act of 1974.

(b) The provisions of sections 38a-478 to 38a-478o, inclusive, sections 38a-591a to 38a-591h, inclusive, and section 38a-591n shall not apply to any plan that provides for the financing or delivery of health care services solely for the purposes of workers’ compensation benefits pursuant to chapter 568.

(P.A. 97-99, S. 28, 30; June 18 Sp. Sess. P.A. 97-8, S. 64, 88; P.A. 99-284, S. 53, 60; P.A. 05-94, S. 4; P.A. 06-54, S. 5; P.A. 11-58, S. 74; P.A. 12-102, S. 9.)

History: June 18 Sp. Sess. P.A. 97-8 amended Subsec. (a) by replacing the exemption for managed care organizations with an exemption for the arrangements of managed care organizations offered to individuals covered under self-insured plans, effective July 1, 1997; P.A. 99-284 deleted obsolete reference to Sec. 38a-514a from Subsec. (b), effective January 1, 2000; P.A. 05-94 deleted references to “managed care organizations” and “employee welfare benefit plans established pursuant to the federal Employee Retirement Income Security Act of 1974”, and referenced “health plans” in Subsec. (a), effective July 1, 2005; P.A. 06-54 amended Subsec. (a) to insert “of managed care organizations or health insurers” and to substitute “self-insured employee welfare benefit plans established pursuant to the federal Employee Retirement Income Security Act of 1974” for “self-insured health plans”, effective May 8, 2006; P.A. 11-58 added references to Secs. 38a-591a to 38a-591h, effective July 1, 2011; P.A. 12-102 added references to Sec. 38a-591n.

Sec. 38a-478t. Commissioner of Public Health to receive data. The Commissioner of Public Health may request and shall receive any data, report or information filed with the Insurance Commissioner pursuant to the provisions of sections 38a-478 to 38a-478u, inclusive, 38a-479aa, 38a-591j, 38a-591k and 38a-993.

(P.A. 97-99, S. 31; P.A. 99-284, S. 54, 60; June Sp. Sess. P.A. 01-4, S. 25; P.A. 11-58, S. 75.)

History: P.A. 99-284 deleted obsolete reference to Sec. 38a-514a, effective January 1, 2000; June Sp. Sess. P.A. 01-4 replaced reference to Sec. 19a-647 with reference to Sec. 38a-479aa; P.A. 11-58 replaced reference to Secs. 38a-226 to 38a-226d with reference to Secs. 38a-591j and 38a-591k, effective July 1, 2011.

Sec. 38a-478u. Regulations. The Insurance Commissioner may adopt regulations in accordance with the provisions of chapter 54 to implement the provisions of sections 38a-478 to 38a-478u, inclusive, 38a-479aa and 38a-993.

(P.A. 97-99, S. 29; P.A. 99-284, S. 55, 60; June Sp. Sess. P.A. 01-4, S. 26; P.A. 03-199, S. 5; P.A. 11-58, S. 76.)

History: P.A. 99-284 deleted obsolete reference to Sec. 38a-514a, effective January 1, 2000; June Sp. Sess. P.A. 01-4 replaced reference to Sec. 19a-647 with reference to Sec. 38a-479aa; P.A. 03-199 substituted “may adopt” for “shall adopt” re regulations; P.A. 11-58 deleted reference to Secs. 38a-226 to 38a-226d, effective July 1, 2011.

Sec. 38a-478v. Applicability of Unfair and Prohibited Insurance Practices Act. Examination by Insurance Commissioner. Regulations. (a) Each managed care organization, as defined in section 38a-478, shall be subject to the provisions of sections 38a-815 to 38a-819, inclusive.

(b) The Insurance Commissioner may examine the affairs of any managed care organization licensed to do business in this state in order to determine whether such managed care organization has been or is engaged in any unfair method of competition or in any unfair or deceptive act or practice prohibited by section 38a-816. The commissioner may adopt regulations, in accordance with the provisions of chapter 54, to implement the provisions of this section.

(P.A. 99-284, S. 31.)

Sec. 38a-479. Definitions. Access to fee schedules. Fee information to be confidential. (a) As used in this section and section 38a-479b:

(1) “Contracting health organization” means a managed care organization, as defined in section 38a-478, or a preferred provider network, as defined in section 38a-479aa.

(2) “Provider” means a physician, surgeon, chiropractor, podiatrist, psychologist, optometrist, natureopath or advanced practice registered nurse licensed in this state or a group or organization of such individuals, who has entered into or renews a participating provider contract with a contracting health organization to render services to such organization’s enrollees and enrollees’ dependents.

(b) Each contracting health organization shall establish and implement a procedure to provide to each provider:

(1) Access via the Internet or other electronic or digital format to the contracting health organization’s fees for (A) the current procedural terminology (CPT) codes applicable to such provider’s specialty, (B) the Health Care Procedure Coding System (HCPCS) codes applicable to such provider, and (C) such CPT codes and HCPCS codes as may be requested by such provider for other services such provider actually bills or intends to bill the contracting health organization, provided such codes are within the provider’s specialty or subspecialty; and

(2) Access via the Internet or other electronic or digital format to the contracting health organization’s policies and procedures regarding (A) payments to providers, (B) providers’ duties and requirements under the participating provider contract, (C) inquiries and appeals from providers, including contact information for the office or offices responsible for responding to such inquiries or appeals and a description of the rights of a provider, enrollee and enrollee’s dependents with respect to an appeal.

(c) The provisions of subdivision (1) of subsection (b) of this section shall not apply to any provider whose services are reimbursed in a manner that does not utilize current procedural terminology codes.

(d) The fee information received by a provider pursuant to subdivision (1) of subsection (b) of this section is proprietary and shall be confidential, and the procedure adopted pursuant to this section may contain penalties for the unauthorized distribution of fee information, which may include termination of the participating provider contract.

(P.A. 06-178, S. 1; P.A. 07-54, S. 2; P.A. 09-204, S. 1; P.A. 11-132, S. 1.)

History: P.A. 07-54 made a technical change in Subsec. (c), effective May 22, 2007; P.A. 09-204 amended Subsec. (a) by deleting former Subdiv. (2) defining “physician” and adding new Subdiv. (2) defining “provider”, amended Subsec. (b) by revising fee schedules and other information contracting health organizations are required to provide to providers and specifying access methodology, deleted former Subsec. (c) re procedure, redesignated existing Subsecs. (d) and (e) as Subsecs. (c) and (d) and made conforming and technical changes, effective January 1, 2010; P.A. 11-132 made a technical change in Subsec. (a)(2).

See Sec. 38a-193 for additional provisions re contracts between health care centers and participating providers.

See Secs. 42-490 to 42-493, inclusive, for provisions re the selling, leasing, renting, assigning or granting of access to a contract or terms of a contract between health care providers and contracting entities.

Sec. 38a-479a. Physicians and managed care organizations to discuss issues relative to contracting between such parties. The chairpersons and ranking members of the joint standing committee of the General Assembly having cognizance of matters relating to insurance shall convene, at least two times each year, a group of physicians and managed care organizations, to discuss issues relative to contracting between physicians and managed care organizations, including issues relative to any national settlement agreements, to the extent permitted under such settlement agreements.

(P.A. 06-178, S. 2.)

Sec. 38a-479b. Material changes to fee schedules. Return of payment by provider. Appeals. Filing of claim by provider under other applicable insurance coverage. Certain clauses, covenants and agreements prohibited. Exception. (a) No contracting health organization shall make material changes to a provider’s fee schedule except as follows:

(1) At one time annually, provided providers are given at least ninety days’ advance notice by mail, electronic mail or facsimile by such organization of any such changes. Upon receipt of such notice, a provider may terminate the participating provider contract with at least sixty days’ advance written notice to the contracting health organization;

(2) At any time for the following, provided providers are given at least thirty days’ advance notice by mail, electronic mail or facsimile by such organization of any such changes:

(A) To comply with requirements of federal or state law, regulation or policy. If such federal or state law, regulation or policy takes effect in less than thirty days, the organization shall give providers as much notice as possible;

(B) To comply with changes to the medical data code sets set forth in 45 CFR 162.1002, as amended from time to time;

(C) To comply with changes to national best practice protocols made by the National Quality Forum or other national accrediting or standard-setting organization based on peer-reviewed medical literature generally recognized by the relevant medical community or the results of clinical trials generally recognized and accepted by the relevant medical community;

(D) To be consistent with changes made in Medicare pertaining to billing or medical management practices, provided any such changes are applied to relevant participating provider contracts where such changes pertain to the same specialty or payment methodology;

(E) If a drug, treatment, procedure or device is identified as no longer safe and effective by the federal Food and Drug Administration or by peer-reviewed medical literature generally recognized by the relevant medical community;

(F) To address payment or reimbursement for a new drug, treatment, procedure or device that becomes available and is determined to be safe and effective by the federal Food and Drug Administration or by peer-reviewed medical literature generally recognized by the relevant medical community; or

(G) As mutually agreed to by the contracting health organization and the provider. If the contracting health organization and the provider do not mutually agree, the provider’s current fee schedule shall remain in force until the annual change permitted pursuant to subdivision (1) of this subsection.

(b) Notwithstanding subsection (a) of this section, a contracting health organization may introduce a new insurance product to a provider at any time, provided such provider is given at least sixty days’ advance notice by mail, electronic mail or facsimile by such organization if the introduction of such insurance product will make material changes to the provider’s administrative requirements under the participating provider contract or to the provider’s fee schedule. The provider may decline to participate in such new product by providing notice to the contracting health organization as set forth in the advance notice, which shall include a period of not less than thirty days for a provider to decline, or in accordance with the time frames under the applicable terms of such provider’s participating provider contract.

(c) (1) No contracting health organization shall cancel, deny or demand the return of full or partial payment for an authorized covered service due to administrative or eligibility error, more than eighteen months after the date of the receipt of a clean claim, except if:

(A) Such organization has a documented basis to believe that such claim was submitted fraudulently by such provider;

(B) The provider did not bill appropriately for such claim based on the documentation or evidence of what medical service was actually provided;

(C) Such organization has paid the provider for such claim more than once;

(D) Such organization paid a claim that should have been or was paid by a federal or state program; or

(E) The provider received payment for such claim from a different insurer, payor or administrator through coordination of benefits or subrogation, or due to coverage under an automobile insurance or workers’ compensation policy. Such provider shall have one year after the date of the cancellation, denial or return of full or partial payment to resubmit an adjusted secondary payor claim with such organization on a secondary payor basis, regardless of such organization’s timely filing requirements.

(2) (A) Such organization shall give at least thirty days’ advance notice to a provider by mail, electronic mail or facsimile of the organization’s cancellation, denial or demand for the return of full or partial payment pursuant to subdivision (1) of this subsection.

(B) If such organization demands the return of full or partial payment from a provider, the notice required under subparagraph (A) of this subdivision shall disclose to the provider (i) the amount that is demanded to be returned, (ii) the claim that is the subject of such demand, and (iii) the basis on which such return is being demanded.

(C) Not later than thirty days after the receipt of the notice required under subparagraph (A) of this subdivision, a provider may appeal such cancellation, denial or demand in accordance with the procedures provided by such organization. Any demand for the return of full or partial payment shall be stayed during the pendency of such appeal.

(D) If there is no appeal or an appeal is denied, such provider may resubmit an adjusted claim, if applicable, to such organization, not later than thirty days after the receipt of the notice required under subparagraph (A) of this subdivision or the denial of the appeal, whichever is applicable, except that if a return of payment was demanded pursuant to subparagraph (C) of subdivision (1) of this subsection, such claim shall not be resubmitted.

(E) A provider shall have one year after the date of the written notice set forth in subparagraph (A) of this subdivision to identify any other appropriate insurance coverage applicable on the date of service and to file a claim with such insurer, health care center or other issuing entity, regardless of such insurer’s, health care center’s or other issuing entity’s timely filing requirements.

(d) Except as provided in subsection (e) of this section, no contracting health organization shall include in any participating provider contract, contract with a dentist or contract with a hospital licensed under chapter 368v, that is entered into, renewed or amended on or after October 1, 2011, or contract offered to a provider, dentist or hospital on or after October 1, 2011, any clause, covenant or agreement that:

(1) Requires the provider, dentist or hospital to:

(A) Disclose to the contracting health organization the provider’s, dentist’s or hospital’s payment or reimbursement rates from any other contracting health organization the provider, dentist or hospital has contracted, or may contract, with;

(B) Provide services or procedures to the contracting health organization at a payment or reimbursement rate equal to or lower than the lowest of such rates the provider, dentist or hospital has contracted, or may contract, with any other contracting health organization;

(C) Certify to the contracting health organization that the provider, dentist or hospital has not contracted with any other contracting health organization to provide services or procedures at a payment or reimbursement rate lower than the rates contracted for with the contracting health organization;

(2) Prohibits or limits the provider, dentist or hospital from contracting with any other contracting health organization to provide services or procedures at a payment or reimbursement rate lower than the rates contracted for with the contracting health organization; or

(3) Allows the contracting health organization to terminate or renegotiate a contract with the provider, dentist or hospital prior to renewal if the provider, dentist or hospital contracts with any other contracting health organization to provide services or procedures at a lower payment or reimbursement rate than the rates contracted for with the contracting health organization.

(e) (1) If a contract described in subsection (d) of this section is in effect prior to October 1, 2011, and includes a clause, covenant or agreement set forth under subdivisions (1) to (3), inclusive, of said subsection (d), such clause, covenant or agreement shall be void and unenforceable on the date such contract is next renewed or on January 1, 2014, whichever is earlier. Such invalidity shall not affect other provisions of such contract.

(2) Nothing in subdivision (1) of this subsection shall be construed to affect the rights of a contracting health organization to enforce such clause, covenant or agreement prior to the invalidation of such clause, covenant or agreement.

(P.A. 09-204, S. 2; P.A. 11-58, S. 16; 11-132, S. 2.)

History: P.A. 09-204 effective July 1, 2010; P.A. 11-58 added new Subsec. (b) re introduction of new insurance products, and redesignated existing Subsec. (b) as Subsec. (c), effective January 1, 2012; P.A. 11-132 added provisions, codified by the Revisors as Subsec. (d), prohibiting certain clauses, covenants or agreements in contracts between contracting health organizations and health care providers and hospitals, and added provisions, codified by the Revisors as Subsec. (e), re exception.

Secs. 38a-479c to 38a-479z. Reserved for future use.

PART Ib

HEALTH INSURANCE: PREFERRED PROVIDER NETWORKS

Sec. 38a-479aa. Preferred provider networks. Definitions. Licensing. Fees. Requirements. Exception, regulations. (a) As used in this part and subsection (b) of section 20-138b:

(1) “Covered benefits” means health care services to which an enrollee is entitled under the terms of a managed care plan;

(2) “Enrollee” means an individual who is eligible to receive health care services through a preferred provider network;

(3) “Health care services” means health care related services or products rendered or sold by a provider within the scope of the provider’s license or legal authorization, and includes hospital, medical, surgical, dental, vision and pharmaceutical services or products;

(4) “Managed care organization” means (A) a managed care organization, as defined in section 38a-478, (B) any other health insurer, or (C) a reinsurer with respect to health insurance;

(5) “Managed care plan” means a managed care plan, as defined in section 38a-478;

(6) “Person” means an individual, agency, political subdivision, partnership, corporation, limited liability company, association or any other entity;

(7) “Preferred provider network” means a person, which is not a managed care organization, but which pays claims for the delivery of health care services, accepts financial risk for the delivery of health care services and establishes, operates or maintains an arrangement or contract with providers relating to (A) the health care services rendered by the providers, and (B) the amounts to be paid to the providers for such services. “Preferred provider network” does not include (i) a workers’ compensation preferred provider organization established pursuant to section 31-279-10 of the regulations of Connecticut state agencies, (ii) an independent practice association or physician hospital organization whose primary function is to contract with insurers and provide services to providers, (iii) a clinical laboratory, licensed pursuant to section 19a-30, whose primary payments for any contracted or referred services are made to other licensed clinical laboratories or for associated pathology services, or (iv) a pharmacy benefits manager responsible for administering pharmacy claims whose primary function is to administer the pharmacy benefit on behalf of a health benefit plan;

(8) “Provider” means an individual or entity duly licensed or legally authorized to provide health care services; and

(9) “Commissioner” means the Insurance Commissioner.

(b) On and after May 1, 2004, no preferred provider network may enter into or renew a contractual relationship with a managed care organization unless the preferred provider network is licensed by the commissioner. On and after May 1, 2005, no preferred provider network may conduct business in this state unless it is licensed by the commissioner. Any person seeking to obtain or renew a license shall submit an application to the commissioner, on such form as the commissioner may prescribe, and shall include the filing described in this subsection, except that a person seeking to renew a license may submit only the information necessary to update its previous filing. Applications shall be submitted by March first of each year in order to qualify for the May first license issue or renewal date. The filing required from such preferred provider network shall include the following information: (1) The identity of the preferred provider network and any company or organization controlling the operation of the preferred provider network, including the name, business address, contact person, a description of the controlling company or organization and, where applicable, the following: (A) A certificate from the Secretary of the State regarding the preferred provider network’s and the controlling company’s or organization’s good standing to do business in the state; (B) a copy of the preferred provider network’s and the controlling company’s or organization’s financial statement completed in accordance with sections 38a-53 and 38a-54, as applicable, for the end of its most recently concluded fiscal year, along with the name and address of any public accounting firm or internal accountant which prepared or assisted in the preparation of such financial statement; (C) a list of the names, official positions and occupations of members of the preferred provider network’s and the controlling company’s or organization’s board of directors or other policy-making body and of those executive officers who are responsible for the preferred provider network’s and controlling company’s or organization’s activities with respect to the health care services network; (D) a list of the preferred provider network’s and the controlling company’s or organization’s principal owners; (E) in the case of an out-of-state preferred provider network, controlling company or organization, a certificate that such preferred provider network, company or organization is in good standing in its state of organization; (F) in the case of a Connecticut or out-of-state preferred provider network, controlling company or organization, a report of the details of any suspension, sanction or other disciplinary action relating to such preferred provider network, or controlling company or organization in this state or in any other state; and (G) the identity, address and current relationship of any related or predecessor controlling company or organization. For purposes of this subparagraph, “related” means that a substantial number of the board or policy-making body members, executive officers or principal owners of both companies are the same; (2) a general description of the preferred provider network and participation in the preferred provider network, including: (A) The geographical service area of and the names of the hospitals included in the preferred provider network; (B) the primary care physicians, the specialty physicians, any other contracting providers and the number and percentage of each group’s capacity to accept new patients; (C) a list of all entities on whose behalf the preferred provider network has contracts or agreements to provide health care services; (D) a table listing all major categories of health care services provided by the preferred provider network; (E) an approximate number of total enrollees served in all of the preferred provider network’s contracts or agreements; (F) a list of subcontractors of the preferred provider network, not including individual participating providers, that assume financial risk from the preferred provider network and to what extent each subcontractor assumes financial risk; (G) a contingency plan describing how contracted health care services will be provided in the event of insolvency; and (H) any other information requested by the commissioner; and (3) the name and address of the person to whom applications may be made for participation.

(c) Any person developing a preferred provider network, or expanding a preferred provider network into a new county, pursuant to this section and subsection (b) of section 20-138b, shall publish a notice, in at least one newspaper having a substantial circulation in the service area in which the preferred provider network operates or will operate, indicating such planned development or expansion. Such notice shall include the medical specialties included in the preferred provider network, the name and address of the person to whom applications may be made for participation and a time frame for making application. The preferred provider network shall provide the applicant with written acknowledgment of receipt of the application. Each complete application shall be considered by the preferred provider network in a timely manner.

(d) (1) Each preferred provider network shall file with the commissioner and make available upon request from a provider the general criteria for its selection or termination of providers. Disclosure shall not be required of criteria deemed by the preferred provider network to be of a proprietary or competitive nature that would hurt the preferred provider network’s ability to compete or to manage health care services. For purposes of this section, criteria is of a proprietary or competitive nature if it has the tendency to cause providers to alter their practice pattern in a manner that would circumvent efforts to contain health care costs and criteria is of a proprietary nature if revealing the criteria would cause the preferred provider network’s competitors to obtain valuable business information.

(2) If a preferred provider network uses criteria that have not been filed pursuant to subdivision (1) of this subsection to judge the quality and cost-effectiveness of a provider’s practice under any specific program within the preferred provider network, the preferred provider network may not reject or terminate the provider participating in that program based upon such criteria until the provider has been informed of the criteria that the provider’s practice fails to meet.

(e) Each preferred provider network shall permit the Insurance Commissioner to inspect its books and records.

(f) Each preferred provider network shall permit the commissioner to examine, under oath, any officer or agent of the preferred provider network or controlling company or organization with respect to the use of the funds of the preferred provider network, company or organization, and compliance with (1) the provisions of this part, and (2) the terms and conditions of its contracts to provide health care services.

(g) Each preferred provider network shall file with the commissioner a notice of any material modification of any matter or document furnished pursuant to this part, and shall include such supporting documents as are necessary to explain the modification.

(h) Each preferred provider network shall maintain a minimum net worth of either (1) the greater of (A) two hundred fifty thousand dollars, or (B) an amount equal to eight per cent of its annual expenditures as reported on its most recent financial statement completed and filed with the commissioner in accordance with sections 38a-53 and 38a-54, as applicable, or (2) another amount determined by the commissioner.

(i) Each preferred provider network shall maintain or arrange for a letter of credit, bond, surety, reinsurance, reserve or other financial security acceptable to the commissioner for the exclusive use of paying any outstanding amounts owed participating providers in the event of insolvency or nonpayment except that any remaining security may be used for the purpose of reimbursing managed care organizations in accordance with subsection (b) of section 38a-479bb. Such outstanding amount shall be at least an amount equal to the greater of (1) an amount sufficient to make payments to participating providers for two months determined on the basis of the two months within the past year with the greatest amounts owed by the preferred provider network to participating providers, (2) the actual outstanding amount owed by the preferred provider network to participating providers, or (3) another amount determined by the commissioner. Such amount may be credited against the preferred provider network’s minimum net worth requirements set forth in subsection (h) of this section. The commissioner shall review such security amount and calculation on a quarterly basis.

(j) Each preferred provider network shall pay the applicable license or renewal fee specified in section 38a-11. The commissioner shall use the amount of such fees solely for the purpose of regulating preferred provider networks.

(k) In no event, including, but not limited to, nonpayment by the managed care organization, insolvency of the managed care organization, or breach of contract between the managed care organization and the preferred provider network, shall a preferred provider network bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against an enrollee or an enrollee’s designee, other than the managed care organization, for covered benefits provided, except that the preferred provider network may collect any copayments, deductibles or other out-of-pocket expenses that the enrollee is required to pay pursuant to the managed care plan.

(l) Each contract or agreement between a preferred provider network and a participating provider shall contain a provision that if the preferred provider network fails to pay for health care services as set forth in the contract, the enrollee shall not be liable to the participating provider for any sums owed by the preferred provider network or any sums owed by the managed care organization because of nonpayment by the managed care organization, insolvency of the managed care organization or breach of contract between the managed care organization and the preferred provider network.

(m) Each utilization review determination made by or on behalf of a preferred provider network shall be made in accordance with section 38a-591d.

(n) The requirements of subsections (h) and (i) of this section shall not apply to a consortium of federally qualified health centers funded by the state, providing services only to recipients of programs administered by the Department of Social Services. The Commissioner of Social Services shall adopt regulations, in accordance with chapter 54, to establish criteria to certify any such federally qualified health center, including, but not limited to, minimum reserve fund requirements.

(June Sp. Sess. P.A. 01-4, S. 21; P.A. 03-169, S. 1; P.A. 06-90, S. 1; 06-196, S. 294; P.A. 07-191, S. 1; 07-200, S. 10; P.A. 08-147, S. 14; 08-184, S. 43; P.A. 11-58, S. 77.)

History: P.A. 03-169 amended Subsec. (a) to substantially revise definitions, amended Subsec. (b) to require licensure before May 1, 2004, or May 1, 2005, for certain activities and to revise filing requirements, amended Subsec. (d) to make technical changes, amended Subsec. (e) to allow the commissioner to inspect books and records, and added new Subsecs. (f) to (m), inclusive, re requirements for preferred provider networks; P.A. 06-90 amended Subsec. (a)(7) to insert clause designators in exclusion from definition of “preferred provider network” and to include in such exclusion, clause (iii) re private clinical laboratory licensed under Sec. 19a-30 whose primary payments for services are made to other licensed clinical laboratories or for associated pathology services, effective May 30, 2006; P.A. 06-196 amended Subsec. (a)(7) by deleting “private” re licensed clinical laboratory in clause (iii), effective June 7, 2006; P.A. 07-191 amended Subsec. (i)(1) to provide that outstanding amount be at least equal to greater of an amount sufficient to make payments to participating providers for two months determined on basis of the two months within past year with greatest amounts owed to providers, rather than two “quarters”, effective July 1, 2007; P.A. 07-200 amended Subsec. (a)(7) to insert as exclusion from definition of “preferred provider network” clause (iv) re pharmacy benefits manager responsible for administering pharmacy claims whose primary function is to administer pharmacy benefit on behalf of a health benefit plan, effective January 1, 2008; P.A. 08-147 and P.A. 08-184 added Subsec. (n) exempting certain federally qualified health centers from requirements of Subsecs. (h) and (i) and requiring Commissioner of Social Services to adopt regulations re criteria to certify such federally qualified health centers, effective June 12, 2008; P.A. 11-58 amended Subsec. (m) to replace reference to Secs. 38a-226 to 38a-226d with “section 38a-591d” and delete provisions re appeals, effective July 1, 2011.

Sec. 38a-479bb. Requirements for managed care organizations that contract with preferred provider networks. Requirements for preferred provider networks. (a) On and after May 1, 2004, no managed care organization may enter into or renew a contractual relationship with a preferred provider network that is not licensed in accordance with section 38a-479aa. On and after May 1, 2005, no managed care organization may continue or maintain a contractual relationship with a preferred provider network that is not licensed in accordance with section 38a-479aa.

(b) Each managed care organization that contracts with a preferred provider network shall (1) post and maintain or require the preferred provider network to post and maintain a letter of credit, bond, surety, reinsurance, reserve or other financial security acceptable to the Insurance Commissioner, in order to satisfy the risk accepted by the preferred provider network pursuant to the contract, in an amount calculated in accordance with subsection (i) of section 38a-479aa, and (2) determine who posts and maintains the security required under subdivision (1) of this subsection. In the event of insolvency or nonpayment such security shall be used by the preferred provider network, or other entity designated by the commissioner, solely for the purpose of paying any outstanding amounts owed participating providers, except that any remaining security may be used for the purpose of reimbursing the managed care organization for any payments made by the managed care organization to participating providers on behalf of the preferred provider network.

(c) Each managed care organization that contracts with a preferred provider network shall provide to the preferred provider network at the time the contract is entered into and annually thereafter:

(1) Information, as determined by the managed care organization, regarding the amount and method of remuneration to be paid to the preferred provider network;

(2) Information, as determined by the managed care organization, to assist the preferred provider network in being informed regarding any financial risk assumed under the contract or agreement, including, but not limited to, enrollment data, primary care provider to covered person ratios, provider to covered person ratios by specialty, a table of the services that the preferred provider network is responsible for, expected or projected utilization rates, and all factors used to adjust payments or risk-sharing targets;

(3) The National Associations of Insurance Commissioners annual statement for the managed care organization; and

(4) Any other information the commissioner may require.

(d) Each managed care organization shall ensure that any contract it has with a preferred provider network includes:

(1) A provision that requires the preferred provider network to provide to the managed care organization at the time a contract is entered into, annually, and upon request of the managed care organization, (A) the financial statement completed in accordance with sections 38a-53 and 38a-54, as applicable, and section 38a-479aa; (B) documentation that satisfies the managed care organization that the preferred provider network has sufficient ability to accept financial risk; (C) documentation that satisfies the managed care organization that the preferred provider network has appropriate management expertise and infrastructure; (D) documentation that satisfies the managed care organization that the preferred provider network has an adequate provider network taking into account the geographic distribution of enrollees and participating providers and whether participating providers are accepting new patients; (E) an accurate list of participating providers; and (F) documentation that satisfies the managed care organization that the preferred provider network has the ability to ensure the delivery of health care services as set forth in the contract;

(2) A provision that requires the preferred provider network to provide to the managed care organization a quarterly status report that includes (A) information updating the financial statement completed in accordance with sections 38a-53 and 38a-54, as applicable, and section 38a-479aa; (B) a report showing amounts paid to those providers who provide health care services on behalf of the managed care organization; (C) an estimate of payments due providers but not yet reported by providers; (D) amounts owed to providers for that quarter; and (E) the number of utilization review determinations not to certify an admission, service, procedure or extension of stay made by or on behalf of the preferred provider network and the outcome of such determination on appeal;

(3) A provision that requires the preferred provider network to provide notice to the managed care organization not later than five business days after (A) any change involving the ownership structure of the preferred provider network; (B) financial or operational concerns arise regarding the financial viability of the preferred provider network; or (C) the preferred provider network’s loss of a license in this or any other state;

(4) A provision that if the managed care organization fails to pay for health care services as set forth in the contract, the enrollee will not be liable to the provider or preferred provider network for any sums owed by the managed care organization or preferred provider network;

(5) A provision that the preferred provider network shall include in all contracts between the preferred provider network and participating providers a provision that if the preferred provider network fails to pay for health care services as set forth in the contract, for any reason, the enrollee shall not be liable to the participating provider or preferred provider network for any sums owed by the preferred provider network or any sums owed by the managed care organization because of nonpayment by the managed care organization, insolvency of the managed care organization or breach of contract between the managed care organization and the preferred provider network;

(6) A provision requiring the preferred provider network to provide information to the managed care organization, satisfactory to the managed care organization, regarding the preferred provider network’s reserves for financial risk;

(7) A provision that (A) the preferred provider network or managed care organization shall post and maintain a letter of credit, bond, surety, reinsurance, reserve or other financial security acceptable to the commissioner, in order to satisfy the risk accepted by the preferred provider network pursuant to the contract, in an amount calculated in accordance with subsection (i) of section 38a-479aa, (B) the managed care organization shall determine who posts and maintains the security required under subparagraph (A) of this subdivision, and (C) in the event of insolvency or nonpayment, such security shall be used by the preferred provider network, or other entity designated by the commissioner, solely for the purpose of paying any outstanding amounts owed participating providers, except that any remaining security may be used for the purpose of reimbursing the managed care organization for any payments made by the managed care organization to participating providers on behalf of the preferred provider network;

(8) A provision under which the managed care organization is permitted, at the discretion of the managed care organization, to pay participating providers directly and in lieu of the preferred provider network in the event of insolvency or mismanagement by the preferred provider network and that payments made pursuant to this subdivision may be made or reimbursed from the security posted pursuant to subsection (b) of this section;

(9) A provision transferring and assigning contracts between the preferred provider network and participating providers to the managed care organization for the provision of future services by participating providers to enrollees, at the discretion of the managed care organization, in the event the preferred provider network (A) becomes insolvent, (B) otherwise ceases to conduct business, as determined by the commissioner, or (C) demonstrates a pattern of nonpayment of authorized claims, as determined by the commissioner, for a period in excess of ninety days;

(10) A provision that each contract or agreement between the preferred provider network and participating providers shall include a provision transferring and assigning contracts between the preferred provider network and participating providers to the managed care organization for the provision of future health care services by participating providers to enrollees, at the discretion of the managed care organization, in the event the preferred provider network (A) becomes insolvent, (B) otherwise ceases to conduct business, as determined by the commissioner, or (C) demonstrates a pattern of nonpayment of authorized claims, as determined by the commissioner, for a period in excess of ninety days;

(11) A provision that the preferred provider network shall pay for the delivery of health care services and operate or maintain arrangements or contracts with providers in a manner consistent with the provisions of law that apply to the managed care organization’s contracts with enrollees and providers; and

(12) A provision that the preferred provider network shall ensure that utilization review determinations are made in accordance with section 38a-591d.

(e) Each managed care organization that contracts with a preferred provider network shall have adequate procedures in place to notify the commissioner that a preferred provider network has experienced an event that may threaten the preferred provider network’s ability to materially perform under its contract with the managed care organization. The managed care organization shall provide such notice to the commissioner not later than five days after it discovers that the preferred provider network has experienced such an event.

(f) Each managed care organization that contracts with a preferred provider network shall monitor and maintain systems and controls for monitoring the financial health of the preferred provider networks with which it contracts.

(g) Each managed care organization that contracts with a preferred provider network shall provide to the commissioner, and update on an annual basis, a contingency plan, satisfactory to the commissioner, describing how health care services will be provided to enrollees if the preferred provider network becomes insolvent or is mismanaged. The contingency plan shall include a description of what contractual and financial steps have been taken to ensure continuity of care to enrollees if the preferred provider network becomes insolvent or is mismanaged.

(h) Notwithstanding any agreement to the contrary, each managed care organization shall retain full responsibility to its enrollees for providing coverage for health care services pursuant to any applicable managed care plan and any applicable state or federal law. Each managed care organization shall exercise due diligence in its selection and oversight of a preferred provider network.

(i) Notwithstanding any agreement to the contrary, each managed care organization shall be able to demonstrate to the satisfaction of the commissioner that the managed care organization can fulfill its nontransferable obligations to provide coverage for the provision of health care services to enrollees in the event of the failure, for any reason, of a preferred provider network.

(j) Each managed care organization that contracts with a preferred provider network shall provide that in the event of the failure, for any reason, of a preferred provider network, the managed care organization shall provide coverage for the enrollee to continue covered treatment with the provider who treated the enrollee under the preferred provider network contract regardless of whether the provider participates in any plan operated by the managed care organization. In the event of such failure, the managed care organization shall continue coverage until the earlier of (1) the date the enrollee’s treatment is completed under a treatment plan that was authorized and in effect on the date of the failure, or (2) the date the contract between the enrollee and the managed care organization terminates. The managed care organization shall compensate a provider for such continued treatment at the rate due the provider under the provider’s contract with the failed preferred provider network.

(k) Each managed care organization that contracts with a preferred provider network shall confirm the information in the quarterly status report submitted by the preferred provider network pursuant to subdivision (2) of subsection (d) of this section and shall submit such information to the commissioner, on such form as the commissioner prescribes, not later than ten days after receiving a request from the commissioner for such information.

(l) (1) Each managed care organization that contracts with a preferred provider network shall certify annually to the commissioner, on such form and in such manner as the commissioner prescribes, that the managed care organization has reviewed the documentation submitted by the preferred provider network pursuant to subdivision (l) of subsection (d) of this section and has determined that the preferred provider network maintains a provider network that is adequate to ensure the delivery of health care services as set forth in the contract. If the commissioner finds that the certification was not submitted in good faith, the commissioner may deem the managed care organization to have not complied with this subsection and may take action pursuant to section 38a-479ee.

(2) If the managed care organization determines that the preferred provider network’s provider network is not adequate and must be increased, the managed care organization shall provide written notice of the determination to the commissioner. Such notice shall describe (A) any plan in place for the preferred provider network to increase its provider network, and (B) the managed care organization’s contingency plan in the event the preferred provider network does not satisfactorily increase its provider network.

(m) Nothing in this part or part 1a of this chapter shall be construed to require a preferred provider network to share proprietary information with a managed care organization concerning contracts or financial arrangements with providers who are not included in that managed care organization’s network, or other preferred provider networks or managed care organizations.

(P.A. 03-169, S. 2; P.A. 07-217, S. 157; P.A. 11-58, S. 78.)

History: P.A. 03-169 effective May 1, 2004; P.A. 07-217 made technical changes in Subsec. (1)(2), effective July 12, 2007; P.A. 11-58 amended Subsec. (d)(12) to replace reference to Secs. 38a-226 to 38a-226d with “section 38a-591d” and delete provisions re appeals, effective July 1, 2011.

Sec. 38a-479cc. Duties of a preferred provider network when providing services pursuant to a contract with a managed care organization. (a) Whenever a preferred provider network is providing services pursuant to a contract with a managed care organization, the preferred provider network may not establish any terms, conditions or requirements for access, diagnosis or treatment that are different from the terms, conditions or requirements for access, diagnosis or treatment in the managed care organization’s plan, except that no preferred provider network shall be required to provide an enrollee access to a provider who does not participate in the preferred provider network unless the preferred provider network is required to provide such access under its contract with the managed care organization.

(b) Whenever a preferred provider network is providing services pursuant to a contract with a managed care organization, the preferred provider network shall pay for the delivery of health care services and operate and maintain arrangements or contracts with providers in a manner consistent with the provisions of law that apply to the managed care organization’s contracts with enrollees and providers.

(P.A. 03-169, S. 3; P.A. 06-196, S. 164.)

History: P.A. 06-196 made a technical change in Subsec. (a), effective June 7, 2006.

Sec. 38a-479dd. Preferred provider network examination of outstanding amounts. Notice. Commissioner’s duties. Each preferred provider network shall examine its outstanding amounts in each quarter and if the preferred provider network determines that the outstanding amounts in a quarter will exceed ninety-five per cent of the security posted pursuant to subsection (i) of section 38a-479aa, the preferred provider network shall mail a notice to each of its participating providers concerning the status of incurred claims and shall send notice to each managed care organization with which it contracts and the Insurance Commissioner on such form as the commissioner prescribes. The commissioner shall meet with the applicable managed care organization and preferred provider network to ensure continued services to enrollees and payment to providers.

(P.A. 03-169, S. 4.)

Sec. 38a-479ee. Violations. Penalties. Investigations and staffing. Grievances. Referrals from Healthcare Advocate. (a) If the Insurance Commissioner determines that a preferred provider network or managed care organization, or both, has not complied with any applicable provision of this part or sections 38a-815 to 38a-819, inclusive, the commissioner may (1) order the preferred provider network or managed care organization, or both if both have not complied, to cease and desist all operations in violation of this part or said sections; (2) terminate or suspend the preferred provider network’s license; (3) institute a corrective action against the preferred provider network or managed care organization, or both if both have not complied; (4) order the payment of a civil penalty by the preferred provider network or managed care organization, or both if both have not complied, of not more than one thousand dollars for each and every act or violation; (5) order the payment of such reasonable expenses as may be necessary to compensate the commissioner in conjunction with any proceedings held to investigate or enforce violations of this part or sections 38a-815 to 38a-819, inclusive; and (6) use any of the commissioner’s other enforcement powers to obtain compliance with this part or sections 38a-815 to 38a-819, inclusive. The commissioner may hold a hearing concerning any matter governed by this part or sections 38a-815 to 38a-819, inclusive, in accordance with section 38a-16. Subject to the same confidentiality and liability protections set forth in subsections (c) and (k) of section 38a-14, the commissioner may engage the services of attorneys, appraisers, independent actuaries, independent certified public accountants or other professionals and specialists to assist the commissioner in conducting an investigation under this section, the cost of which shall be borne by the managed care organization or preferred provider network, or both, that is the subject of the investigation.

(b) If a preferred provider network fails to comply with any applicable provision of this part or sections 38a-815 to 38a-819, inclusive, the commissioner may assign or require the preferred provider network to assign its rights and obligations under any contract with participating providers in order to ensure that covered benefits are provided.

(c) The commissioner shall receive and investigate (1) any grievance filed against a preferred provider network or managed care organization, or both, by an enrollee or an enrollee’s designee concerning matters governed by this part or sections 38a-815 to 38a-819, inclusive, or (2) any referral from the Office of the Healthcare Advocate pursuant to section 38a-1041. The commissioner shall code, track and review such grievances and referrals. The preferred provider network or managed care organization, or both, shall provide the commissioner with all information necessary for the commissioner to investigate such grievances and referrals. The information collected by the commissioner pursuant to this section shall be maintained as confidential and shall not be disclosed to any person except (A) to the extent necessary to carry out the purposes of this part or sections 38a-815 to 38a-819, inclusive, (B) as allowed under this title, (C) to the Healthcare Advocate, and (D) information concerning the nature of any grievance or referral and the commissioner’s final determination shall be a public record, as defined in section 1-200, provided no personal information, as defined in section 38a-975, shall be disclosed. The commissioner shall report to the Healthcare Advocate on the resolution of any matter referred to the commissioner by the Healthcare Advocate.

(P.A. 03-169, S. 5; P.A. 05-102, S. 6; P.A. 11-58, S. 79.)

History: P.A. 05-102 amended Subsec. (c) by renaming the Office of Managed Care Ombudsman the Office of the Healthcare Advocate and making conforming changes; P.A. 11-58 deleted references to Secs. 38a-226 to 38a-226d, effective July 1, 2011.

Sec. 38a-479ff. Adverse action or threat of adverse action against complainant prohibited. Exception. Civil actions by aggrieved persons. No health insurer, health care center, utilization review company, as defined in section 38a-591a, or preferred provider network, as defined in section 38a-479aa, shall take or threaten to take any adverse personnel or coverage-related action against any enrollee, provider or employee in retaliation for such enrollee, provider or employee (1) filing a complaint with the Insurance Commissioner or the Office of the Healthcare Advocate, or (2) disclosing information to the Insurance Commissioner concerning any violation of this part or sections 38a-815 to 38a-819, inclusive, unless such disclosure violates the provisions of chapter 705 or the privacy provisions of the federal Health Insurance Portability and Accountability Act of 1996, P.L. 104-191, as amended from time to time, or regulations adopted thereunder. Any enrollee, provider or employee who is aggrieved by a violation of this section may bring a civil action in the Superior Court to recover damages and attorneys’ fees and costs.

(P.A. 03-169, S. 6; P. A. 05-102, S. 7; P.A. 11-58, S. 80.)

History: P.A. 05-102 renamed the Office of Managed Care Ombudsman the Office of the Healthcare Advocate; P.A. 11-58 replaced reference to Sec. 38a-226 with “section 38a-591a”, deleted reference to Secs. 38a-226 to 38a-226d and made a technical change, effective July 1, 2011.

Sec. 38a-479gg. Regulations. The Insurance Commissioner may adopt regulations, in accordance with chapter 54, to implement the provisions of this part.

(P.A. 03-169, S. 7.)

Secs. 38a-479hh to 38a-479pp. Reserved for future use.

PART Ic

HEALTH INSURANCE: MEDICAL DISCOUNT PLANS

Sec. 38a-479qq. Medical discount plans: Definitions, prohibited sales practices, penalties. (a) As used in this section and section 38a-479rr:

(1) “Affiliate” means a person that directly or indirectly through one or more intermediaries, controls, or is controlled by, or is under common control with, a health insurer, health care center, hospital service corporation, medical service corporation or fraternal benefit society licensed in this state;

(2) “Consumer” means: (A) A person to whom a medical discount plan is marketed or advertised, or (B) a member, as defined in this subsection;

(3) “Marketer” means a person that markets, advertises or sells a medical discount plan, including, but not limited to, an entity that markets, advertises or sells a medical discount plan under its own name;

(4) “Medical discount plan” means a business arrangement or contract in which a person, in exchange for payment, provides access for its members to providers of health care services and the right to receive health care services from those providers at a discount. “Medical discount plan” does not include a product that (A) is otherwise subject to regulation or approval under this title, or (B) costs less than twenty-five dollars, annually, in the aggregate;

(5) “Medical discount plan organization” means a person that (A) establishes a medical discount plan, (B) contracts with providers, provider networks or other medical discount plan organizations to provide health care services at a discount to medical discount plan members, and (C) determines the fees charged to the members for the medical discount plan. “Medical discount plan organization” does not include a health insurer, health care center, hospital service corporation, medical service corporation or fraternal benefit society licensed in this state or any affiliate of such health insurer, health care center, hospital service corporation, medical service corporation or fraternal benefit society;

(6) “Health care services” means any care, service or treatment of an illness or dysfunction of, or injury to, the human body. “Health care services” includes physician care, inpatient care, hospital surgical services, emergency medical services, ambulance services, dental care services, vision care services, mental health care services, substance abuse services, chiropractic services, podiatric services, laboratory test services and the provision of medical equipment or supplies. “Health care services” does not include pharmaceutical supplies or prescriptions;

(7) “Member” means an individual who pays for the right to receive the benefits of a medical discount plan; and

(8) “Person” means a person, as defined in section 38a-1.

(b) No person shall market, advertise or sell to a resident of this state a medical discount plan or any plan material that: (1) Fails to provide to the consumer a clear and conspicuous disclosure that the medical discount plan is not insurance and that the plan only provides for discounted health care services from participating providers within the plan; (2) uses in its marketing materials, advertisements, brochures or member discount cards the term “insurance”, “health plan”, “coverage”, “copay”, “copayments”, “preexisting conditions”, “guaranteed issue”, “premium”, “PPO”, “preferred provider organization” or any other term that could reasonably mislead a person into believing the medical discount plan is insurance, except that such terms may be used as a disclaimer of any relationship between the medical discount plan and insurance; (3) fails to provide the name, address and telephone number of the administrator of the medical discount plan; (4) fails to make available to the consumer through a toll-free telephone number, upon request of the consumer, a complete and accurate list of the participating providers within the plan in the consumer’s local area and a list of the services for which the discounts are applicable; (5) fails to make a printed copy of such list available to the consumer upon request commencing with the time the plan is purchased or fails to update the list at least once every six months; (6) fails to use plain language to describe the discounts or access to discounts offered and such failure results in representations of the discounts that are misleading, deceptive or fraudulent; (7) fails to provide the consumer notice of the right to cancel such medical discount plan; (8) offers discounted health care services or products that are not authorized by a contract with each provider listed in conjunction with the medical discount plan; (9) fails to allow a consumer to cancel a medical discount plan not later than thirty days after the date payment is received by the medical discount plan; (10) with respect to a consumer who cancels a medical discount plan pursuant to subdivision (9) of this subsection, fails to guarantee a refund of all membership fees paid to the medical discount plan by the consumer, excluding a reasonable one-time processing fee, not later than thirty days after the member gives timely notification of cancellation of the plan to the medical discount plan organization; or (11) fails to (A) provide at least one member discount card for each member as proof of membership, and (B) prominently display on such member discount card a statement that the medical discount plan is not insurance.

(c) Any person who knowingly operates as a medical discount plan organization in violation of this section shall be fined not more than fifteen thousand dollars. Any person who knowingly aids and abets another that the person knew or reasonably should have known was operating as a medical discount plan organization in violation of this section shall be fined not more than fifteen thousand dollars.

(d) Any person who collects fees for purported membership in a medical discount plan but fails to provide the promised benefits shall be subject to the penalties for larceny under sections 53a-122 to 53a-125b, inclusive, depending on the amount involved. Upon the conviction of such person of larceny, as defined in section 53a-119, if the court does not order financial restitution pursuant to section 53a-28, the commissioner may order reimbursement of any membership fees paid by residents of the state who were harmed by such offense.

(e) Any person licensed in this state as a health insurer, health care center, hospital service corporation, medical service corporation or fraternal benefit society, or any affiliate owned or controlled by such health insurer, health care center, hospital service corporation, medical service corporation or fraternal benefit society, may offer medical discount plans in this state pursuant to such licensure.

(P.A. 05-237, S. 1; P.A. 08-178, S. 51; 08-181, S. 1.)

History: P.A. 05-237 effective July 1, 2005; P.A. 08-178 increased maximum fines from $10,000 to $15,000 in Subsec. (c); P.A. 08-181 added Subsec. (a)(3) defining “marketer”, redesignated existing Subsecs. (a)(3) to (a)(7) as new Subsecs. (a)(4) to (a)(8), amended Subsec. (b) by changing “may” to “shall”, and amended Subsec. (d) by authorizing commissioner to order additional penalty of membership fees reimbursement.

Sec. 38a-479rr. Medical discount plan organizations: Licensure. List of authorized marketers. Provider agreements. Minimum net worth. Suspension of authority and revocation or nonrenewal of license. Reinstatement of license. Maintenance of information. Regulations. Penalties. Advertising and marketing materials. Investigations. (a) Before doing business in this state as a medical discount plan organization, an entity shall:

(1) Be a corporation, limited liability company, limited liability partnership, or other legal entity organized under the laws of this state or, if a foreign corporation or other foreign entity, authorized to transact business in this state; and

(2) Obtain a license as a medical discount plan organization from the Insurance Commissioner in accordance with this section. The entity shall file an application for a license to operate as a medical discount plan organization with the commissioner on such form as the commissioner prescribes. Such application shall be sworn to by an officer or authorized representative of the applicant, under penalty of false statement, and be accompanied by (A) a copy of the applicant’s articles of incorporation, including all amendments; (B) a copy of the applicant’s bylaws; (C) a list of the names, addresses, official positions and biographical information of the medical discount plan organization and the individuals who are responsible for conducting the applicant’s affairs, including, but not limited to, all members of the board of directors, board of trustees, executive committee, or other governing board or committee, the officers, contracted management company personnel, and any person or entity owning or having the right to acquire ten per cent or more of the voting securities of the applicant, which listing shall fully disclose the extent and nature of any contracts or arrangements between the applicant and any individual who is responsible for conducting the applicant’s affairs, including any possible conflicts of interest; (D) for each individual listed in subparagraph (C) of this subdivision as being responsible for conducting the applicant’s affairs, a complete biographical statement on forms prescribed by the commissioner; (E) a statement generally describing the applicant, its personnel and the health care services to be offered; (F) a copy of the form of all contracts made or to be made between the applicant and any providers or provider networks regarding the provision of health care services to members; (G) a copy of the form of any contract made or to be made between the applicant and any person listed in subparagraph (C) of this subdivision; (H) a copy of the form of any contract made or to be made between the applicant and any person for the performance on the applicant’s behalf of any function, including, but not limited to, marketing, administration, enrollment and subcontracting for the provision of health care services to members; (I) a copy of the applicant’s most recent financial statements audited by an independent certified public accountant, or, in the case of an applicant that is a subsidiary of a person or parent corporation that prepares audited financial statements reflecting the consolidated operations of the person or parent corporation, a copy of the person’s or parent corporation’s most recent financial statements audited by an independent certified public accountant, provided the person or parent corporation also issues a written guarantee that the minimum capital requirements of the applicant required by this section will be met; (J) a description of the proposed method of marketing; (K) a description of the subscriber complaint procedures to be established and maintained; (L) the fee for a medical discount plan organization license set forth in section 38a-11; and (M) a list of the names, addresses and telephone numbers of the marketers the applicant has authorized to market a medical discount plan in this state under a name that is different from the name of the applicant. For purposes of this subdivision, a “contract to be made” shall be determined based on the information known to the applicant on the date the information is filed with the commissioner.

(b) (1) A current and accurate list of authorized marketers, specified in subparagraph (M) of subdivision (2) of subsection (a) of this section, shall be submitted to the commissioner with each renewal fee, as set forth in subsection (c) of this section.

(2) Any change made to the list of authorized marketers, specified in subparagraph (M) of subdivision (2) of subsection (a) of this section, shall be electronically filed with the commissioner. If such change is to add a marketer to a medical discount plan organization’s list of authorized marketers, such change shall be electronically filed by such organization prior to the marketer doing business in the state for such organization.

(3) The commissioner may adopt regulations, in accordance with chapter 54, to establish the procedure and format of the electronic filing set forth in this subsection.

(c) If the commissioner finds that the applicant is in compliance with the requirements of this section the commissioner shall issue the applicant a license as a medical discount plan organization which shall expire one year after the date of issue. The commissioner shall renew the license if the commissioner finds that the licensee is in compliance with the requirements of this section and the licensee has paid the renewal fee set forth in section 38a-11.

(d) Prior to applying for a license from the commissioner, a medical discount plan organization shall establish an Internet web site that contains the information described in subsection (s) of this section.

(e) Any license or renewal fee received pursuant to this section shall be deposited in the Insurance Fund established in section 38a-52a.

(f) Nothing in this section shall require a provider who provides discounts to the provider’s own patients to obtain or maintain a license as a medical discount plan organization.

(g) Each provider who offers health care services to members under a medical discount plan shall provide such services pursuant to a written agreement. The agreement may be entered into directly by the provider or by a provider network to which the provider belongs.

(h) A provider agreement shall include: (1) A list of the services and products to be provided at a discount; (2) the amount of the discounts or, alternatively, a fee schedule that reflects the provider’s discounted rates; and (3) a requirement that the provider will not charge members more than the discounted rates.

(i) A provider agreement between a medical discount plan organization and a provider network shall require that the provider network have written agreements with its providers that: (1) Contain the terms set forth in subsection (h) of this section; (2) authorize the provider network to contract with the medical discount plan organization on behalf of the provider; and (3) require the network to maintain an up-to-date list of its contracted providers and to provide that list on a quarterly basis to the medical discount plan organization. No medical discount plan organization may enter into or renew a contractual relationship with a provider network that is not licensed in accordance with section 38a-479aa.

(j) The medical discount plan organization shall maintain a copy of each active agreement that it has entered into with a provider or provider network.

(k) Each medical discount plan organization shall at all times (1) maintain a net worth of at least two hundred fifty thousand dollars, or (2) post a surety bond in the amount of one hundred thousand dollars.

(l) The commissioner shall not issue or renew a license under this section unless the medical discount plan organization has (1) a net worth of at least two hundred fifty thousand dollars, or (2) posted a surety bond in the amount of one hundred thousand dollars.

(m) The commissioner may suspend the authority of a medical discount plan organization to enroll new members, revoke any license issued to a medical discount plan organization, refuse to renew a license of a medical discount plan organization or order compliance if the commissioner finds that any of the following conditions exist:

(1) The organization is not operating in compliance with this section or section 38a-479qq;

(2) The organization does not have the minimum net worth required by this section;

(3) The organization has advertised, sold or attempted to sell its services in such a manner as to misrepresent its services or capacity for service or has engaged in deceptive, misleading or unfair practices with respect to advertising or sales;

(4) The organization is not fulfilling its obligations as a medical discount plan organization; or

(5) The continued operation of the medical discount plan organization would be hazardous to its members.

(n) If the commissioner has reasonable cause to believe that grounds for the suspension, nonrenewal or revocation of a license exist, the commissioner shall notify the medical discount plan organization in writing specifically stating the grounds for suspension, nonrenewal or revocation.

(o) When the license of a medical discount plan organization is surrendered, nonrenewed or revoked, the organization shall, immediately following the effective date of the order, wind up and settle the affairs transacted under the license. The organization shall not engage in any further marketing, advertising, sales, collection of fees or renewal of contracts as a medical discount plan organization, and its authorized marketers shall not engage in any further marketing, advertising or sales on behalf of such medical discount plan organization.

(p) The commissioner shall, in any order suspending the authority of a medical discount plan organization to enroll new members, specify the period during which the suspension is to be in effect and the conditions, if any, which must be met by the medical discount plan organization prior to reinstatement of its license to enroll new members. The commissioner may rescind or modify the order of suspension prior to the expiration of the suspension period.

(q) The commissioner shall not reinstate a license: (1) Unless reinstatement is requested by the medical discount plan organization, and (2) if the commissioner finds that the circumstances which led to the suspension still exist or are likely to recur.

(r) Each medical discount plan organization shall provide the commissioner at least thirty days’ advance written notice of any change in the medical discount plan organization’s name, address, principal business address or mailing address.

(s) Each medical discount plan organization shall maintain an up-to-date list of the names and addresses of the providers with which it has contracted on an Internet web site, the address of which shall be prominently displayed on all its marketing materials, advertisements, brochures and member discount cards. The list shall include providers with whom the medical discount plan organization has contracted directly as well as providers who will provide services to the organization’s members as part of a provider network with which the medical discount plan organization has contracted.

(t) Each medical discount plan organization shall (1) prominently display on any member discount card the names or identifying logos or trademarks of any provider networks with whom the medical discount plan organization has a contract, and (2) provide the names of such provider networks to members upon request.

(u) No marketer shall market, advertise or sell to a resident of this state a medical discount plan under a name that is different than the medical discount plan organization’s name unless: (1) The medical discount plan organization has obtained a license from the Insurance Commissioner in accordance with this section; (2) the marketer is listed on such medical discount plan organization’s list of authorized marketers as set forth in subparagraph (M) of subdivision (2) of subsection (a) or subsection (b) of this section; (3) the name, address and telephone number of the medical discount plan organization appears on the plan materials; and (4) the marketer does not contract directly with providers or provider networks. A marketer shall not be required to obtain a license from the commissioner.

(v) (1) A medical discount plan organization may market directly or contract with marketers for the distribution of a medical discount plan. The medical discount plan organization shall execute a written agreement with a marketer and comply with the requirements set forth in subparagraph (M) of subdivision (2) of subsection (a) or subsection (b) of this section, as applicable, prior to the marketing, advertising or selling of such medical discount plan by such marketer. Such written agreement shall prohibit the marketer from using any advertising and marketing materials, including, but not limited to, brochures and medical discount plan cards, without the written approval of the medical discount plan organization prior to the usage of such advertising and marketing materials.

(2) If a marketer uses any marketing or advertising materials that are in violation of subsection (b) of section 38a-479qq, the commissioner may order a medical discount plan organization to immediately remove such marketer from such medical discount plan organization’s list of authorized marketers specified in subparagraph (M) of subdivision (2) of subsection (a) of this section. In addition, the commissioner may order the medical discount plan organization to return membership fees paid by residents of the state who were harmed by such violation.

(3) During an investigation by the commissioner of an alleged violation set forth in subdivision (2) of this subsection, a medical discount plan organization shall make available to the commissioner, upon request, a copy of such organization’s contract with such marketer, and any marketing and advertising materials of such marketer.

(w) Each medical discount plan organization that contracts with a marketer shall be bound by and responsible for the activities of such marketer, within the scope of the marketer’s agency relationship, and shall cooperate in any investigation of the activities of such contracted marketer as ordered by the commissioner.

(x) The commissioner may adopt regulations, in accordance with chapter 54, to implement the provisions of this section.

(y) Any person who violates any provision of this section shall be fined not more than three thousand dollars.

(P.A. 05-237, S. 2; P.A. 08-178, S. 52; 08-181, S. 2; P.A. 10-5, S. 17.)

History: P.A. 05-237 effective January 1, 2006; P.A. 08-178 increased maximum fine from $2,000 to $3,000 in Subsec. (u); P.A. 08-181 made technical changes, amended Subsec. (a)(2) by adding Subpara. (M) re list of authorized marketers, added new Subsec. (b) re submission of list of authorized marketers, redesignated existing Subsecs. (b) to (s) as new Subsecs. (c) to (t) and made conforming changes, amended new Subsec. (o) by prohibiting authorized marketers from engaging in further marketing, advertising or sales on behalf of a medical discount plan organization whose license has been surrendered, nonrenewed or revoked, inserted new Subsec. (u) re prerequisites for marketers, new Subsec. (v) re required written agreement and access to materials by commissioner during an investigation and new Subsec. (w) re liability of medical discount plan organization for activities of its marketers and requirement to cooperate in an investigation, and redesignated existing Subsecs. (t) and (u) as Subsecs. (x) and (y); P.A. 10-5 amended Subsec. (b)(3) by deleting “and acknowledgement”, effective May 5, 2010.

Secs. 38a-479ss to 38a-479zz. Reserved for future use.

PART Id

HEALTH INSURANCE: PHARMACY BENEFITS MANAGERS

Sec. 38a-479aaa. Pharmacy benefits managers. Definitions. As used in this section and sections 38a-479bbb to 38a-479hhh, inclusive:

(1) “Commissioner” means the Insurance Commissioner;

(2) “Department” means the Insurance Department;

(3) “Drug” means drug, as defined in section 21a-92;

(4) “Person” means person, as defined in section 38a-1;

(5) “Pharmacist services” includes (A) drug therapy and other patient care services provided by a licensed pharmacist intended to achieve outcomes related to the cure or prevention of a disease, elimination or reduction of a patient’s symptoms, and (B) education or intervention by a licensed pharmacist intended to arrest or slow a disease process;

(6) “Pharmacist” means an individual licensed to practice pharmacy under section 20-590, 20-591, 20-592 or 20-593, and who is thereby recognized as a health care provider by the state of Connecticut;

(7) “Pharmacy” means a place of business where drugs may be sold at retail and for which a pharmacy license has been issued to an applicant pursuant to section 20-594; and

(8) “Pharmacy benefits manager” or “manager” means any person that administers the prescription drug, prescription device, pharmacist services or prescription drug and device and pharmacist services portion of a health benefit plan on behalf of plan sponsors such as self-insured employers, insurance companies, labor unions and health care centers.

(P.A. 07-200, S. 1.)

History: P.A. 07-200 effective January 1, 2008.

Sec. 38a-479bbb. Registration of pharmacy benefits managers required. Application for registration. Fee. Surety bond. Exemption from registration. (a) Except as provided in subsection (d) of this section, no person shall act as a pharmacy benefits manager in this state without first obtaining a certificate of registration from the commissioner.

(b) Any person seeking a certificate of registration shall apply to the commissioner, in writing, on a form provided by the commissioner. The application form shall state (1) the name, address, official position and professional qualifications of each individual responsible for the conduct of the affairs of the pharmacy benefits manager, including all members of the board of directors, board of trustees, executive committee, other governing board or committee, the principal officers in the case of a corporation, the partners or members in the case of a partnership or association and any other person who exercises control or influence over the affairs of the pharmacy benefits manager, and (2) the name and address of the applicant’s agent for service of process in this state.

(c) Each application for a certificate of registration shall be accompanied by (1) a nonrefundable fee of fifty dollars, and (2) evidence of a surety bond in an amount equivalent to ten per cent of one month of claims in this state over a twelve-month average, except that such bond shall not be less than twenty-five thousand dollars or more than one million dollars.

(d) Any pharmacy benefits manager operating as a line of business or affiliate of a health insurer, health care center, hospital service corporation, medical service corporation or fraternal benefit society licensed in this state or any affiliate of such health insurer, health care center, hospital service corporation, medical service corporation or fraternal benefit society shall not be required to obtain a certificate of registration. Such health insurer, health care center, hospital service corporation, medical service corporation or fraternal benefit society shall notify the commissioner annually, in writing, on a form provided by the commissioner, that it is affiliated with or operating a business as a pharmacy benefits manager.

(e) Any person acting as a pharmacy benefits manager on January 1, 2008, and required to obtain a certificate of registration under subsection (a) of this section, shall obtain a certificate of registration from the commissioner not later than April 1, 2008, in order to continue to do business in this state.

(P.A. 07-200, S. 2.)

History: P.A. 07-200 effective January 1, 2008.

Sec. 38a-479ccc. Certificate of registration; when issued or refused. Suspension, revocation or refusal to issue or renew registration; grounds. (a) Upon receipt of a completed application, evidence of a surety bond and fee, the commissioner shall: (1) Issue and deliver to the applicant a certificate of registration; or (2) refuse to issue the certificate.

(b) The commissioner may suspend, revoke or refuse to issue or renew any certificate of registration for: (1) Conduct of a character likely to mislead, deceive or defraud the public or the commissioner; (2) unfair or deceptive business practices; or (3) nonpayment of the renewal fee.

(c) The commissioner shall not suspend or revoke any certificate of registration except upon notice and hearing in accordance with chapter 54.

(P.A. 07-200, S. 3.)

History: P.A. 07-200 effective January 1, 2008.

Sec. 38a-479ddd. Hearing on denial of certificate. Subsequent application. (a) Upon refusal to issue or renew a certificate, the commissioner shall notify the applicant of the denial and of the applicant’s right to request a hearing within ten days from the date of receipt of the notice of denial.

(b) If the applicant requests a hearing within such ten days, the commissioner shall give notice of the grounds for the commissioner’s refusal and shall conduct a hearing concerning such refusal in accordance with the provisions of chapter 54 concerning contested cases.

(c) If the commissioner’s denial of a certificate is sustained after such hearing, an applicant may make a new application not less than one year after the date on which such denial was sustained.

(P.A. 07-200, S. 4.)

History: P.A. 07-200 effective January 1, 2008.

Sec. 38a-479eee. Investigations and hearings. Powers of commissioner. The commissioner may conduct investigations and hold hearings on any matter under the provisions of sections 38a-479aaa to 38a-479hhh, inclusive. The commissioner may issue subpoenas, administer oaths, compel testimony and order the production of books, records and documents. If any person refuses to appear, to testify or to produce any book, record, paper or document when so ordered, upon application of the commissioner, a judge of the Superior Court may make such order as may be appropriate to aid in the enforcement of this section.

(P.A. 07-200, S. 5.)

History: P.A. 07-200 effective January 1, 2008.

Sec. 38a-479fff. Expiration of certificates of registration. Renewal. Fees. (a) All certificates of registration issued under section 38a-479ccc shall expire annually on December thirty-first.

(b) Any person seeking to renew a certificate of registration shall apply to the commissioner, in writing, on a form provided by the commissioner. The application for renewal shall be in such form as the commissioner prescribes. Such application shall be accompanied by a nonrefundable fee of fifty dollars. Any late payment of such fee shall include a penalty fee of fifty dollars.

(P.A. 07-200, S. 6.)

History: P.A. 07-200 effective January 1, 2008.

Sec. 38a-479ggg. Regulations. The commissioner shall adopt regulations, in accordance with chapter 54, to implement the provisions of sections 38a-479aaa to 38a-479hhh, inclusive. Such regulations shall specify the contents of the application form and any other form or report required under the provisions of said sections.

(P.A. 07-200, S. 7.)

History: P.A. 07-200 effective January 1, 2008.

Sec. 38a-479hhh. Appeals. Any person aggrieved by an order or decision of the commissioner under sections 38a-479aaa to 38a-479hhh, inclusive, may appeal therefrom in accordance with the provisions of section 4-183.

(P.A. 07-200, S. 8.)

History: P.A. 07-200 effective January 1, 2008.

PART II

INDIVIDUAL HEALTH INSURANCE

Sec. 38a-480. (Formerly Sec. 38-174). Nonapplication to certain policies or contracts. (a) Nothing in sections 38a-481 to 38a-488, inclusive, shall apply to or affect (1) any policy of liability or workers’ compensation insurance; (2) any group health insurance policy as defined by the commissioner; (3) life insurance, endowment or annuity contracts or contracts supplemental thereto which contain only such provisions relating to health insurance as (A) provide additional benefits in case of death by accidental means and (B) operate to safeguard such contracts against lapse, or to give a special surrender value or special benefit or an annuity in the event that the insured or annuitant becomes totally and permanently disabled as defined by the contract or supplemental contract; (4) fraternal benefit societies, except as provided by section 38a-640; (5) insurance, issued in conjunction with an automobile liability policy subject to sections 38a-19 and 38a-363 to 38a-388, inclusive, providing reimbursement for medical, surgical, ambulance, hospital, nursing or funeral expenses, or indemnity for other loss, resulting from injuries sustained by any person, including the named insured, arising out of the ownership, maintenance or use of an automobile, or issued in conjunction with other kinds of liability insurance providing reimbursement for medical, surgical, ambulance, hospital, nursing or funeral expenses resulting from injuries sustained by any person, including the named insured, in connection with the premises or operations insured.

(b) The provisions of sections 38a-481 to 38a-488, inclusive, 38a-492, 38a-502 and 38a-505 shall not apply to any subscriber contract issued by a health care center.

(1949 Rev., S. 6188; 1951, 1953, S. 2842d; 1957, P.A. 448, S. 46; 1967, P.A. 326; P.A. 79-376, S. 59; P.A. 88-326, S. 5; P.A. 90-243, S. 71.)

History: 1967 act added proviso in Subdiv. (2) re furnishing of information which insurer would be required to certify to plan administrator under federal Welfare and Pension Plans Disclosure Act; P.A. 79-376 added reference to Secs. 38-166 to 38-172 and substituted “workers’ compensation” for “workmen’s compensation”; P.A. 88-326 required the commissioner to adopt regulations establishing a procedure for review of group health and accident policies, life insurance policies and annuity contracts, and added a new Subsec. (b) concerning the commissioner’s disapproval of any policy form; P.A. 90-243 substituted reference to “group health insurance policy” for reference to accident and health policies, deleted former provisions re commissioner’s approval of forms and re group policies and added a new Subsec. (b) exempting health care centers from certain statutory provisions; Sec. 38-174 transferred to Sec. 38a-480 in 1991.

Sec. 38a-481. (Formerly Sec. 38-165). Approval of individual health application, policy form and rates. Medicare supplement policies and certificates: Age, gender, previous claim or medical history rating prohibited. Loss ratios. Regulations. Certain refunds to be donated to The University of Connecticut Health Center. Underwriting classifications, claim experience and health status. Exceptions. Use of certain prescription drug history prohibited. (a) No individual health insurance policy shall be delivered or issued for delivery to any person in this state, nor shall any application, rider or endorsement be used in connection with such policy, until a copy of the form thereof and of the classification of risks and the premium rates have been filed with the commissioner. The commissioner shall adopt regulations, in accordance with chapter 54, to establish a procedure for reviewing such policies. The commissioner shall disapprove the use of such form at any time if it does not comply with the requirements of law, or if it contains a provision or provisions which are unfair or deceptive or which encourage misrepresentation of the policy. The commissioner shall notify, in writing, the insurer which has filed any such form of the commissioner’s disapproval, specifying the reasons for disapproval, and ordering that no such insurer shall deliver or issue for delivery to any person in this state a policy on or containing such form. The provisions of section 38a-19 shall apply to such orders.

(b) No rate filed under the provisions of subsection (a) of this section shall be effective until the expiration of thirty days after it has been filed or unless sooner approved by the commissioner in accordance with regulations adopted pursuant to this subsection. The commissioner shall adopt regulations, in accordance with chapter 54, to prescribe standards to ensure that such rates shall not be excessive, inadequate or unfairly discriminatory. The commissioner may disapprove such rate within thirty days after it has been filed if it fails to comply with such standards, except that no rate filed under the provisions of subsection (a) of this section for any Medicare supplement policy shall be effective unless approved in accordance with section 38a-474.

(c) No insurance company, fraternal benefit society, hospital service corporation, medical service corporation, health care center or other entity which delivers or issues for delivery in this state any Medicare supplement policies or certificates shall incorporate in its rates or determinations to grant coverage for Medicare supplement insurance policies or certificates any factors or values based on the age, gender, previous claims history or the medical condition of any person covered by such policy or certificate.

(d) Rates on a particular policy form shall not be deemed excessive if the insurer has filed a loss ratio guarantee with the Insurance Commissioner which meets the requirements of subsection (e) of this section provided (1) the form of such loss ratio guarantee has been explicitly approved by the Insurance Commissioner, and (2) the current expected lifetime loss ratio is not more than five per cent less than the filed lifetime loss ratio as certified by an actuary. The insurer shall withdraw the policy form if the commissioner determines that the lifetime loss ratio will not be met. Rates also will not be deemed excessive if the insurer complies with the terms of the loss ratio guarantee. The Insurance Commissioner may adopt regulations, in accordance with chapter 54, to assure that the use of a loss ratio guarantee does not constitute an unfair practice.

(e) Premium rates shall be deemed approved upon filing with the Insurance Commissioner if the filing is accompanied by a loss ratio guarantee. The loss ratio guarantee shall be in writing, signed by an officer of the insurer, and shall contain as a minimum the following:

(1) A recitation of the anticipated lifetime and durational target loss ratios contained in the original actuarial memorandum filed with the policy form when it was originally approved;

(2) A guarantee that the actual Connecticut loss ratios for the experience period in which the new rates take effect and for each experience period thereafter until any new rates are filed will meet or exceed the loss ratios referred to in subdivision (1) of this subsection. If the annual earned premium volume in Connecticut under the particular policy form is less than one million dollars and therefore not actuarially credible, the loss ratio guarantee will be based on the actual nation-wide loss ratio for the policy form. If the aggregate earned premium for all states is less than one million dollars, the experience period will be extended until the end of the calendar year in which one million dollars of earned premium is attained;

(3) A guarantee that the actual Connecticut or nation-wide loss ratio results, as the case may be, for the experience period at issue will be independently audited by a certified public accountant or a member of the American Academy of Actuaries at the insurer’s expense. The audit shall be done in the second quarter of the year following the end of the experience period and the audited results must be reported to the Insurance Commissioner not later than June thirtieth following the end of the experience period;

(4) A guarantee that affected Connecticut policyholders will be issued a proportional refund, which will be based on the premiums earned, of the amount necessary to bring the actual loss ratio up to the anticipated loss ratio referred to in subdivision (1) of this subsection. If nation-wide loss ratios are used, the total amount refunded in Connecticut shall equal the dollar amount necessary to achieve the loss ratio standards multiplied by the total premium earned from all Connecticut policyholders who will receive refunds and divided by the total premium earned in all states on the policy form. The refund shall be made to all Connecticut policyholders who are insured under the applicable policy form as of the last day of the experience period and whose refund would equal two dollars or more. The refund shall include interest, at six per cent, from the end of the experience period until the date of payment. Payment shall be made during the third quarter of the year following the experience period for which a refund is determined to be due;

(5) A guarantee that refunds less than two dollars will be aggregated by the insurer. The insurer shall deposit such amount in a separate interest-bearing account in which all such amounts shall be deposited. At the end of each calendar year each such insurer shall donate such amount to The University of Connecticut Health Center;

(6) A guarantee that the insurer, if directed by the Insurance Commissioner, shall withdraw the policy form and cease the issuance of new policies under the form in this state if the applicable loss ratio exceeds the durational target loss ratio for the experience period by more than twenty per cent, provided the calculations are based on at least two thousand policyholder-years of experience either in Connecticut or nation-wide.

(f) For the purposes of this section:

(1) “Loss ratio” means the ratio of incurred claims to earned premiums by the number of years of policy duration for all combined durations; and

(2) “Experience period” means the calendar year for which a loss ratio guarantee is calculated.

(g) Nothing in this chapter shall preclude the issuance of an individual health insurance policy which includes an optional life insurance rider, provided the optional life insurance rider must be filed with and approved by the Insurance Commissioner pursuant to section 38a-430. Any company offering such policies for sale in this state shall be licensed to sell life insurance in this state pursuant to the provisions of section 38a-41.

(h) No insurance company, fraternal benefit society, hospital service corporation, medical service corporation, health care center or other entity that delivers, issues for delivery, amends, renews or continues an individual health insurance policy in this state shall: (1) Move an insured individual from a standard underwriting classification to a substandard underwriting classification after the policy is issued; (2) increase premium rates due to the claim experience or health status of an individual who is insured under the policy, except that the entity may increase premium rates for all individuals in an underwriting classification due to the claim experience or health status of the underwriting classification as a whole; or (3) use an individual’s history of taking a prescription drug for anxiety for six months or less as a factor in its underwriting unless such history arises directly from a medical diagnosis of an underlying condition.

(1949 Rev., S. 6177; 1951, S. 2835d; 1967, P.A. 437, S. 1; P.A. 78-280, S. 6, 127; P.A. 88-230, S. 1, 12; 88-326, S. 4; P.A. 90-243, S. 72; P.A. 91-311; P.A. 93-390, S. 5, 8; P.A. 96-51, S. 2; P.A. 03-119, S. 1; P.A. 05-20, S. 3; P.A. 09-123, S. 1; P.A. 10-5, S. 18; P.A. 11-19, S. 29; P.A. 12-145, S. 11.)

History: 1967 act added Subsec. (b) re effective date of rates and rate standards; P.A. 78-280 replaced “Hartford county” with “judicial district of Hartford-New Britain” in Subsec. (a); P.A. 88-230 proposed to replace reference to “judicial district of Hartford-New Britain” with “judicial district of Hartford”, effective September 1, 1991, but said reference was deleted by P.A. 88-326; P.A. 88-326 required the commissioner to adopt regulations establishing a procedure for policy review and rephrased existing provisions; P.A. 90-243 substituted reference to “individual health insurance policy” for references to insurance against loss from sickness, bodily injury or accidental death; Sec. 38-165 transferred to Sec. 38a-481 in 1991; P.A. 91-311 amended Subsec. (b) to exclude Medicare supplement policy rates unless filed in accordance with Sec. 38a-474, added a new Subsec. (c) re filing of the required loss ratio guarantee form to preclude the claim that a particular policy has excessive rates and added the discretionary authority for the commissioner to adopt regulations re the terms of the loss ratio guarantee, added a new Subsec. (d) re premium rates if filed with a loss ratio guarantee and outlining the minimum requirements of a loss ratio guarantee in order to meet the commissioner’s approval, the refund procedure for Connecticut policyholders and the procedures by which a policy form can be withdrawn and added Subsec. (e) defining “loss ratio” and “experience period”; P.A. 93-390 inserted new Subsec. (c) prohibiting the incorporation of factors for age, gender, previous claim or medical condition history into the insurer’s rate schedule and relettered the remaining Subsecs. and internal references accordingly, effective January 1, 1994; P.A. 96-51 added Subsec. (g) to permit optional life insurance riders; P.A. 03-119 added Subsec. (h) re underwriting classifications; P.A. 05-20 made technical changes and amended provisions re regulations throughout, amended Subsec. (c) re Medicare supplements to reference “determinations to grant coverage” and plans “H” to “J”, inclusive, “issued prior to January 1, 2006,” re use of claims history and medical condition, amended Subsec. (d) to insert Subdiv. designators (1) and (2), and amended Subsec. (e)(5) to delete provisions re donations to Uncas-on-Thames Hospital, effective July 1, 2005; P.A. 09-123 amended Subsec. (h) by adding Subdiv. (3) prohibiting use of certain prescription drug history of an individual in underwriting and making technical changes, effective January 1, 2010; P.A. 10-5 made a technical change in Subsec. (b), effective May 5, 2010; P.A. 11-19 amended Subsec. (c) to delete provisions re Medicare supplement plans “H” to “J”; P.A. 12-145 made a technical change in Subsec. (d), effective June 15, 2012.

See Sec. 38a-477a re notification by Insurance Commissioner of required benefits and policy forms.

See Sec. 38a-504 re insurance policy or contract requirements covering surgical removal of tumors and treatment of leukemia.

Annotation to former section 38-165:

Cited. 186 C. 507.

Sec. 38a-482. (Formerly Sec. 38-166). Form of policy. No individual health insurance policy shall be delivered or issued for delivery to any person in this state unless: (1) The entire money and other considerations therefor are expressed therein; (2) the time at which the insurance takes effect and terminates is expressed therein; (3) such policy purports to insure only one person, except that a policy may insure, originally or by subsequent amendment, upon the application of an adult member of a family, who shall be deemed the policyholder, any two or more eligible members of such family, including husband, wife, dependent children or any children as specified in section 38a-497, and any other person dependent upon the policyholder; (4) the style, arrangement and overall appearance of the policy give no undue prominence to any portion of the text, and every printed portion of the text of the policy and of any endorsements or attached papers is plainly printed in light-faced type of a style in general use, the size of which shall be uniform and not less than ten-point with a lowercase unspaced alphabet length not less than one hundred and twenty-point, the word “text” as herein used including all printed matter except the name and address of the insurer, name or title of the policy, the brief description, if any, and captions and subcaptions; (5) the exceptions and reductions of indemnity are set forth in the policy and, except as provided in section 38a-483, are printed, at the insurer’s option, either included with the benefit provision to which they apply, or under an appropriate caption such as “EXCEPTIONS” or “EXCEPTIONS AND REDUCTIONS”, provided, if an exception or reduction specifically applies only to a particular benefit of the policy, a statement of such exception or reduction shall be included with the benefit provision to which it applies; (6) each such form, including riders and endorsements, shall be identified by a form number in the lower left-hand corner of the first page thereof; and (7) such policy contains no provision purporting to make any portion of the charter, rules, constitution or bylaws of the insurer a part of the policy unless such portion is set forth in full in the policy, except in the case of the incorporation of, or reference to, a statement of rates or classification of risks, or short-rate table filed with the commissioner.

(1949 Rev., S. 6178; 1951, S. 2836d; 1972, P.A. 127, S. 63; P.A. 90-243, S. 73; P.A. 07-185, S. 15.)

History: 1972 act changed maximum insurable age of children in Subsec. (a)(3) from 19 to 18, reflecting changed age of majority; P.A. 90-243 added reference to “individual health insurance” and deleted former Subsec. (b); Sec. 38-166 transferred to Sec. 38a-482 in 1991; P.A. 07-185 amended Subdiv. (3) re age of children who may be insured under adult family member’s individual health insurance policy by replacing provision re specified age not to exceed 18 years with reference to Sec. 38a-497, effective July 1, 2007.

Annotations to former section 38-166:

Cited. 214 C. 303.

Sec. 38a-482a. Individual health insurance policy to contain definition of “medically necessary” or “medical necessity”. (a) No insurer, health care center, hospital service corporation, medical service corporation or other entity delivering, issuing for delivery, renewing, continuing or amending any individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469 in this state shall deliver or issue for delivery in this state any such policy unless such policy contains a definition of “medically necessary” or “medical necessity” as follows: “Medically necessary” or “medical necessity” means health care services that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are: (1) In accordance with generally accepted standards of medical practice; (2) clinically appropriate, in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and (3) not primarily for the convenience of the patient, physician or other health care provider and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease. For the purposes of this subsection, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community or otherwise consistent with the standards set forth in policy issues involving clinical judgment.

(b) The provisions of subsection (a) of this section shall not apply to any insurer, health care center, hospital service corporation, medical service corporation or other entity that has entered into any national settlement agreement until the expiration of any such agreement.

(P.A. 07-75, S. 1; P.A. 11-19, S. 21.)

History: P.A. 07-75 effective January 1, 2008; P.A. 11-19 made technical changes.

See Sec. 38a-513c for similar provisions re group policies.

Sec. 38a-482b. Individual health insurance policy providing limited coverage to include disclosure. Limited coverage defined. (a) Each individual health insurance policy, subscriber contract or certificate of coverage delivered or issued for delivery in this state on or after January 1, 2008, that provides limited coverage, and any marketing material, application for coverage and enrollment material relative to such policy, contract or certificate, shall include the following statement printed in capital letters in not less than twelve-point bold face type and located in a conspicuous manner on such document:

“THIS LIMITED HEALTH BENEFITS PLAN DOES NOT PROVIDE COMPREHENSIVE MEDICAL COVERAGE. IT IS A BASIC OR LIMITED BENEFITS POLICY AND IS NOT INTENDED TO COVER ALL MEDICAL EXPENSES. THIS PLAN IS NOT DESIGNED TO COVER THE COSTS OF SERIOUS OR CHRONIC ILLNESS. IT CONTAINS SPECIFIC DOLLAR LIMITS THAT WILL BE PAID FOR MEDICAL SERVICES WHICH MAY NOT BE EXCEEDED. IF THE COST OF SERVICES EXCEEDS THOSE LIMITS, THE BENEFICIARY AND NOT THE INSURER IS RESPONSIBLE FOR PAYMENT OF THE EXCESS AMOUNTS. THE SPECIFIC DOLLAR LIMITS ARE AS FOLLOWS: (INSURER TO SPECIFY SUCH AMOUNTS).”

(b) For the purposes of this section, “limited coverage” means an insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 that contains an annual maximum benefit of less than one hundred thousand dollars or fixed dollar benefits of less than twenty thousand dollars on any core services. For the purpose of this section, “core services” means medical, surgical and hospital services, including inpatient and outpatient physician, laboratory and imaging services.

(P.A. 07-96, S. 1; P.A. 08-147, S. 11.)

History: P.A. 07-96 effective July 1, 2007; P.A. 08-147 redefined “limited coverage” in Subsec. (b) to specify fixed dollar benefits of less than $20,000 on any core services.

See Sec. 38a-513d for similar provisions re group policies.

Sec. 38a-482c. Lifetime limit. (a) No individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state shall include a lifetime limit on the dollar value of benefits for a covered individual, for covered benefits that are essential health benefits, as defined in the Patient Protection and Affordable Care Act, P.L. 111-1448, as amended from time to time, or regulations adopted thereunder.

(b) This section shall not prohibit the inclusion of a lifetime limit on specific covered benefits that are not essential health benefits, provided the lifetime limit for reasonable charges or, when applicable, the allowance agreed upon by a health care provider and an insurer, health care center, hospital service corporation, medical service corporation or fraternal benefit society for charges actually incurred for any specific covered benefit, shall be not less than one million dollars per covered individual.

(P.A. 11-58, S. 42.)

History: P.A. 11-58 effective July 2, 2011.

See Sec. 38a-512c for similar provisions re group policies.

Sec. 38a-483. (Formerly Sec. 38-167). Standard provisions of individual health policy. (a) Except as provided in subsection (c) of this section, each individual health insurance policy delivered or issued for delivery to any person in this state shall contain the provisions specified in this subsection in the words in which the same appear in this section; provided the insurer may, at its option, substitute for one or more of such provisions corresponding provisions of different wording approved by the commissioner which are in each instance not less favorable in any respect to the insured or the beneficiary. Such provisions shall be preceded individually by the caption appearing in this subsection or, at the option of the insurer, by such appropriate individual or group captions or subcaptions as the commissioner may approve. Such provisions to be contained in such policy shall be:

(1) A provision as follows: “ENTIRE CONTRACT: CHANGES: This policy, including the endorsements and the attached papers, if any, constitutes the entire contract of insurance. No change in this policy shall be valid until approved by an executive officer of the insurer and unless such approval be endorsed hereon or attached hereto. No agent has authority to change this policy or to waive any of its provisions.”

(2) A provision as follows: “TIME LIMIT ON CERTAIN DEFENSES: This policy shall be incontestable, except for nonpayment of premium, after it has been in force for two years from its date of issue.”

(3) A provision as follows: “GRACE PERIOD: A grace period of .... (insert a number not less than seven for weekly premium policies, ten for monthly premium policies and thirty-one for all other policies) days will be granted for the payment of each premium falling due after the first premium, during which grace period the policy shall continue in force.” A policy which contains a cancellation provision may add, at the end of the above provision, “subject to the right of the insurer to cancel in accordance with the cancellation provision hereof.” A policy in which the insurer reserves the right to refuse any renewal may have, at the beginning of the above provision, “Unless not less than five days prior to the premium due date the insurer has delivered to the insured or has mailed to his last address as shown by the records of the insurer written notice of its intention not to renew this policy beyond the period for which the premium has been accepted.”

(4) A provision as follows: “REINSTATEMENT: If any renewal premium is not paid within the time granted the insured for payment, a subsequent acceptance of premium by the insurer or by any agent duly authorized by the insurer to accept such premium, without requiring in connection therewith an application for reinstatement, shall reinstate the policy; provided, if the insurer or such agent requires an application for reinstatement and issues a conditional receipt for the premium tendered, the policy shall be reinstated upon approval of such application by the insurer or, lacking such approval, upon the forty-fifth day following the date of such conditional receipt unless the insurer has previously notified the insured, in writing, of its disapproval of such application. The reinstated policy shall cover only loss resulting from such accidental injury as may be sustained after the date of reinstatement and loss due to such sickness as may begin more than ten days after such date. In all other respects the insured and insurer shall have the same rights thereunder as they had under the policy immediately before the due date of the defaulted premium, subject to any provisions endorsed hereon or attached hereto in connection with the reinstatement. Any premium accepted in connection with a reinstatement shall be applied to a period for which premium has not been previously paid, but not to any period more than sixty days prior to the date of reinstatement.” The last sentence of the above provision may be omitted from any policy which the insured has the right to continue in force subject to its terms by the timely payment of premiums (1) until at least age fifty or (2), in the case of a policy issued after age forty-four, for at least five years from its date of issue.

(5) A provision as follows: “NOTICE OF CLAIM: Written notice of claim must be given to the insurer within twenty days after the occurrence or commencement of any loss covered by the policy, or as soon thereafter as is reasonably possible. Notice given by or on behalf of the insured or the beneficiary to the insurer at .... (insert the location of such office as the insurer may designate for the purpose), or to any authorized agent of the insurer, with information sufficient to identify the insured, shall be deemed notice to the insurer.” In a policy providing a loss-of-time benefit which may be payable for at least two years, an insurer may, at its option, insert the following between the first and second sentences of the above provision: “Subject to the qualifications set forth below, if the insured suffers loss of time on account of disability for which indemnity may be payable for at least two years, he shall, at least once in every six months after having given notice of claim, give to the insurer notice of continuance of said disability, except in the event of legal incapacity. The period of six months following any filing of proof by the insured or any payment by the insurer on account of such claim or any denial of liability in whole or in part by the insurer shall be excluded in applying this provision. Delay in the giving of such notice shall not impair the insured’s right to any indemnity which would otherwise have accrued during the period of six months preceding the date on which such notice is actually given.”

(6) A provision as follows: “CLAIM FORMS: The insurer, upon receipt of a notice of claim, shall furnish to the claimant such forms as are usually furnished by it for filing proofs of loss. If such forms are not furnished within fifteen days after the giving of such notice, the claimant shall be deemed to have complied with the requirements of this policy as to proof of loss, upon submitting, within the time fixed in the policy for filing proofs of loss, written proof covering the occurrence, the character and the extent of the loss for which claim is made.”

(7) A provision as follows: “PROOFS OF LOSS: Written proof of loss shall be furnished to the insurer at its said office in case of claim for loss for which this policy provides any periodic payment contingent upon continuing loss within ninety days after the termination of the period for which the insurer is liable and in case of claim for any other loss within ninety days after the date of such loss. Failure to furnish such proof within the time required shall not invalidate nor reduce any claim if it was not reasonably possible to give proof within such time, provided such proof is furnished as soon as reasonably possible and in no event, except in the absence of legal capacity, later than one year from the time proof is otherwise required.”

(8) A provision as follows: “TIME OF PAYMENT OF CLAIMS: Indemnities payable under this policy for any loss other than loss for which this policy provides any periodic payment will be paid immediately upon receipt of due written proof of such loss. Subject to due written proof of loss, all accrued indemnities for loss for which this policy provides periodic payment shall be paid .... (insert period for payment which must not be less frequently than monthly) and any balance remaining unpaid upon the termination of liability will be paid immediately upon receipt of due written proof.”

(9) A provision as follows: “PAYMENT OF CLAIMS: Indemnity for loss of life will be payable in accordance with the beneficiary designation and the provisions respecting such payment which may be prescribed herein and effective at the time of payment. If no such designation or provision is then effective, such indemnity shall be payable to the estate of the insured. Any other accrued indemnities unpaid at the insured’s death may, at the option of the insurer, be paid either to such beneficiary or to such estate. All other indemnities will be payable to the insured.” The following provisions, or either of them, may be included with the foregoing provision at the option of the insurer: “If any indemnity of this policy shall be payable to the estate of the insured, or to an insured or beneficiary who is a minor or otherwise not competent to give a valid release, the insurer may pay such indemnity, up to an amount not exceeding $.... (insert an amount which shall not exceed one thousand dollars), to any relative by blood or connection by marriage of the insured or beneficiary who is deemed by the insurer to be equitably entitled thereto. Any payment made by the insurer in good faith pursuant to this provision shall fully discharge the insurer to the extent of such payment. Subject to any written direction of the insured in the application or otherwise, all or a portion of any indemnities provided by this policy on account of hospital, nursing, medical or surgical services may, at the insurer’s option and unless the insured requests otherwise in writing not later than the time of filing proofs of such loss, be paid directly to the hospital or person rendering such services; but it is not required that the service be rendered by a particular hospital or person.”

(10) A provision as follows: “PHYSICAL EXAMINATIONS AND AUTOPSY: The insurer at its own expense shall have the right and opportunity to examine the person of the insured when and as often as it may reasonably require during the pendency of a claim hereunder and to make an autopsy in case of death where it is not forbidden by law.”

(11) A provision as follows: “LEGAL ACTIONS: No action at law or in equity shall be brought to recover on this policy prior to the expiration of sixty days after written proof of loss has been furnished in accordance with the requirements of this policy. No such action shall be brought after the expiration of three years after the time written proof of loss is required to be furnished.”

(12) A provision as follows: “CHANGE OF BENEFICIARY: Unless the insured makes an irrevocable designation of beneficiary, the right to change of beneficiary is reserved to the insured and the consent of the beneficiary or beneficiaries shall not be requisite to surrender or assignment of this policy or to any change of beneficiary or beneficiaries, or to any other changes in this policy.” The first clause of this provision, relating to the irrevocable designation of beneficiary, may be omitted at the insurer’s option.

(b) Except as provided in subsection (c) of this section, no such policy delivered or issued for delivery to any person in this state shall contain provisions respecting the matters set forth below unless such provisions are in the words in which the same appear in this section; provided the insurer may, at its option, use in lieu of any such provision a corresponding provision of different wording approved by the commissioner which is not less favorable in any respect to the insured or the beneficiary. Any such provision contained in the policy shall be preceded individually by the appropriate caption appearing in this subsection or, at the option of the insurer, by such appropriate individual or group captions or subcaptions as the commissioner may approve.

(1) A provision as follows: “CHANGE OF OCCUPATION: If the insured be injured or contract sickness after having changed his occupation to one classified by the insurer as more hazardous than that stated in his policy or while doing for compensation anything pertaining to an occupation so classified, the insurer will pay only such portion of the indemnities provided in this policy as the premium paid would have purchased at the rates and within the limits fixed by the insurer for such more hazardous occupation. If the insured changes his occupation to one classified by the insurer as less hazardous than that stated in this policy, the insurer, upon receipt of proof of such change of occupation, will reduce the premium rate accordingly, and will return the excess pro-rata unearned premium from the date of change of occupation or from the policy anniversary date immediately preceding receipt of such proof, whichever is the more recent. In applying this provision, the classification of occupational risk and the premium rates shall be such as have been last filed by the insurer prior to the occurrence of the loss for which the insurer is liable or prior to date of proof of change in occupation with the state official having supervision of insurance in the state where the insured resided at the time this policy was issued; but if such filing was not required, then the classification of occupational risk and the premium rates shall be those last made effective by the insurer in such state prior to the occurrence of the loss or prior to the date of proof of change in occupation.”

(2) A provision as follows: “MISSTATEMENT OF AGE: If the age of the insured has been misstated, all amounts payable under this policy shall be such as the premium paid would have purchased at the correct age.”

(3) A provision in accordance with subparagraph (i) or (ii) of this subdivision as follows: (i) “OTHER INSURANCE IN THIS INSURER: If an accident or sickness or accident and sickness policy or policies previously issued by the insurer to the insured be in force concurrently herewith, making the aggregate indemnity for .... (insert type of coverage or coverages) in excess of $.... (insert maximum limit of indemnity or for such excess shall be returned to the insured or his estate”; or, (ii) “OTHER INSURANCE IN THIS INSURER: Insurance effective at any one time on the insured under a like policy or policies in this insurer is limited to the one such policy elected by the insured, his beneficiary or his estate, as the case may be, and the insurer will return all premiums paid for all other such policies.”

(4) A provision as follows: “INSURANCE WITH OTHER INSURERS: If there be other valid coverage, not with this insurer, providing benefits for the same loss on a provision of service basis or on an expense incurred basis and of which this insurer has not been given written notice prior to the occurrence or commencement of loss, the only liability under any expense incurred coverage of this policy shall be for such proportion of the loss as the amount which would otherwise have been payable hereunder plus the total of the like amounts under all such other valid coverages for the same loss of which this insurer had notice bears to the total like amounts under all valid coverages for such loss, and for the return of such portion of the premiums paid as shall exceed the pro-rata portion for the amount so determined. For the purpose of applying this provision when other coverage is on a provision of service basis, the “like amount” of such other coverage shall be taken as the amount which the services rendered would have cost in the absence of such coverage.” If the foregoing policy provision is included in a policy which also contains the policy provisions specified in subdivision (5) of this subsection, there shall be added to the caption of the foregoing provision the phrase “– EXPENSE INCURRED BENEFITS”. The insurer may, at its option, include in this provision a definition of “other valid coverage”, approved as to form by the commissioner, which definition shall be limited in subject matter to coverage provided by organizations subject to regulation by insurance law or by insurance authorities of this or any other state of the United States or any province of Canada, and by hospital or medical service organizations, and to any other coverage the inclusion of which may be approved by the commissioner. In the absence of such definition, such terms shall not include group insurance, automobile medical payments insurance, or coverage provided by hospital or medical service organizations or by union welfare plans or employer or employee benefit organizations. For the purpose of applying the foregoing policy provision with respect to any insured, any amount of benefit provided for such insured pursuant to any compulsory benefit statute, including any workers’ compensation or employer’s liability statute, whether provided by a governmental agency or otherwise, shall in all cases be deemed to be “other valid coverage” of which the insurer has had notice. In applying the foregoing policy provision no third party liability coverage shall be included as “other valid coverage”.

(5) A provision as follows: “INSURANCE WITH OTHER INSURERS: If there be other valid coverage, not with this insurer, providing benefits for the same loss on other than an expense incurred basis and of which this insurer has not been given written notice prior to the occurrence or commencement of loss, the only liability for such benefits under this policy shall be for such proportion of the indemnities otherwise provided hereunder for such loss as the like indemnities of which the insurer had notice (including the indemnities under this policy) bear to the total amount of all like indemnities for such loss, and for the return of such portion of the premium paid as shall exceed the pro-rata portion for the indemnities thus determined.” If the foregoing policy provision is included in a policy which also contains the policy provision specified in subdivision (4) of this subsection, there shall be added to the caption of the foregoing provision the phrase “– OTHER BENEFITS”. The insurer may, at its option, include in this provision a definition of “other valid coverage”, approved as to form by the commissioner, which definition shall be limited in subject matter to coverage provided by organizations subject to regulation by insurance law or by insurance authorities of this or any other state of the United States or any province of Canada, and to any other coverage the inclusion of which may be approved by the commissioner. In the absence of such definition, such term shall not include group insurance, or benefits provided by union welfare plans or by employer or employee benefit organizations. For the purpose of applying the foregoing policy provision with respect to any insured, any amount of benefit provided for such insured pursuant to any compulsory benefit statute including any workers’ compensation or employer’s liability statute, whether provided by a governmental agency or otherwise shall in all cases be deemed to be “other valid coverage” of which the insurer has had notice. In applying the foregoing policy provision no third party liability coverage shall be included as “other valid coverage”.

(6) A provision as follows: “RELATION OF EARNINGS TO INSURANCE: If the total monthly amount of loss of time benefits promised for the same loss under all valid loss of time coverage upon the insured, whether payable on a weekly or monthly basis, shall exceed the monthly earnings of the insured at the time disability commenced or his average monthly earnings for the period of two years immediately preceding a disability for which claim is made, whichever is the greater, the insurer will be liable only for such proportionate amount of such benefits under this policy as the amount of such monthly earnings or such average monthly earnings of the insured bears to the total amount of monthly benefits for the same loss under all such coverage upon the insured at the time such disability commences and for the return of such part of the premiums paid during such two years as shall exceed the pro-rata amount of the premiums for the benefits actually paid hereunder; but this shall not operate to reduce the total monthly amount of benefits payable under all such coverage upon the insured below the sum of two hundred dollars or the sum of the monthly benefits specified in such coverages, whichever is the lesser, nor shall it operate to reduce benefits other than those payable for loss of time.” The foregoing policy provision may be inserted only in a policy which the insured has the right to continue in force subject to its terms by the timely payment of premiums (1) until at least age fifty, or (2) in the case of a policy issued after age forty-four, for at least five years from its date of issue. The insurer may, at its option, include in this provision a definition of “valid loss of time coverage”, approved as to form by the commissioner, which definition shall be limited in subject matter to coverage provided by governmental agencies or by organizations subject to regulation by insurance law or by insurance authorities of this or any other state of the United States or any province of Canada, or to any other coverage the inclusion of which may be approved by the commissioner or any combination of such coverages. In the absence of such definition such term shall not include any coverage provided for such insured pursuant to any compulsory benefit statute, including any workers’ compensation or employer’s liability statute, or benefits provided by union welfare plans or by employer or employee benefit organizations.

(7) A provision as follows: “UNPAID PREMIUM: Upon the payment of a claim under this policy, any premium then due and unpaid or covered by any note or written order may be deducted therefrom.”

(8) A provision as follows: “CANCELLATION: The insurer may cancel this policy at any time by written notice delivered to the insured and to any dependents who were listed on the application and any subsequent revisions thereto, or mailed to their last address as shown by the records of the insurer, stating when, not less than five days thereafter, such cancellation shall be effective; and after the policy has been continued beyond its original term the insured may cancel this policy at any time by written notice delivered or mailed to the insurer, effective upon receipt or on such later date as may be specified in such notice. In the event of cancellation, the insurer will return promptly the unearned portion of any premium paid. If the insured cancels, the earned premium shall be computed by the use of the short-rate table last filed with the state official having supervision of insurance in the state where the insured resided when the policy was issued. If the insurer cancels, the earned premium shall be computed pro-rata. Cancellation shall be without prejudice to any claim originating prior to the effective date of cancellation.”

(9) A provision as follows: “CONFORMITY WITH STATE STATUTES: Any provision of this policy which, on its effective date, is in conflict with the statutes of the state in which the insured resides on such date is hereby amended to conform to the minimum requirements of such statutes.”

(c) If any provision of this section is in whole or in part inapplicable to or inconsistent with the coverage provided by a particular form of policy, the insurer, with the approval of the commissioner, shall omit from such policy any inapplicable provision or part of a provision, and shall modify any inconsistent provision or part of the provision in such manner as to make the provision as contained in the policy consistent with the coverage provided by the policy.

(d) The provisions specified in subsections (a) and (b) of this section, or any corresponding provisions which are used in lieu thereof in accordance with said subsections, shall be printed in the consecutive order of the provisions in such subsections or, at the option of the insurer, any such provision may appear as a unit in any part of the policy, with other provisions to which it may be logically related, provided the resulting policy shall not be in whole or in part unintelligible, uncertain, ambiguous, abstruse or likely to mislead a person to whom the policy is offered, delivered or issued.

(e) The word “insured”, as used in sections 38a-481 to 38a-488, inclusive, shall not be construed as preventing a person other than the insured with a proper insurable interest from making application for and owning a policy covering the insured or from being entitled under such a policy to any indemnities, benefits and rights provided therein.

(f) (1) Any policy of a foreign or alien insurer, when delivered or issued for delivery to any person in this state, may contain any provision which is not less favorable to the insured or the beneficiary than the provisions of sections 38a-481 to 38a-488, inclusive, and which is prescribed or required by the law of the state under which the insurer is organized.

(2) Any policy of a domestic insurer may, when issued for delivery in any other state or country, contain any provision permitted or required by the laws of such other state or country.

(g) The commissioner may make such reasonable rules and regulations concerning the procedure for the filing or submission of policies subject to sections 38a-481 to 38a-488, inclusive, as are necessary, proper or advisable to the administration of said sections. This provision shall not abridge any other authority granted the commissioner by law.

(1949 Rev., S. 6179, 6180, 6186; Apps. B, C; 1951, S. 2837d; 1971, P.A. 267; P.A. 79-376, S. 58; P.A. 90-243, S. 74; P.A. 95-40; P.A. 10-5, S. 19.)

History: 1971 act replaced previous provisions re “time limit on defenses” which had detailed voidance of policy because of misstatements on application with provision stating that policy is uncontestable except for premium nonpayment after it is in force for two years; P.A. 79-376 substituted “workers’ compensation” for “workmen’s compensation” where appearing; P.A. 90-243 added reference to “an individual health insurance” policy; Sec. 38-167 transferred to Sec. 38a-483 in 1991; P.A. 95-40 added requirement to Subsec. (b)(8) that written notice be delivered not only to the insured but also to any dependents listed on the application and any subsequent revisions thereto; (Revisor’s note: When P.A. 95-40, which amended Subsec. (b)(8) concerning “CANCELLATION”, was incorporated into the section by the Revisors, the unamended text of Subsec. (b)(8) was inadvertently moved to and replaced the then existing Subsec. (a)(8) concerning “TIME OF PAYMENT OF CLAIMS”. Since there was no legislation in 1995, or subsequently, making any changes to Subsec. (a)(8), the Revisors editorially corrected their 1995 codification error by reinstating the correct wording of Subsec. (a)(8) for the 2001 revision); P.A. 10-5 made a technical change in Subsec. (b)(6), effective May 5, 2010.

Annotation to former section 38-167:

Gardener setting off a single bomb on fourth of July held not to have changed occupation to a more hazardous one. 91 C. 729.

Annotation to present section:

Subsec. (a):

“Entire contract” provision does not prohibit insurer from incorporating by reference its underwriting income rules in an increase option rider to a disability insurance policy, when application of those rules can neither decrease nor eliminate a fixed benefit of original policy. 273 C. 12.

Sec. 38a-483a. Exclusionary riders for individual health insurance policies. Regulations. Notwithstanding the provisions of section 38a-476, the Insurance Commissioner may adopt regulations, in accordance with the provisions of chapter 54, to allow exclusionary riders to be issued for individual health insurance policies that are not subject to Section 2701 of the Public Health Service Act, as set forth in the Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191) (HIPAA), as amended from time to time.

(June 18 Sp. Sess. P.A. 97-8, S. 71, 88.)

History: June 18 Sp. Sess. P.A. 97-8 effective July 1, 1997.

Sec. 38a-483b. Time limits for coverage determinations. Notice requirements. Except as otherwise provided in this title, each insurer, health care center, hospital service corporation, medical service corporation or other entity delivering, issuing for delivery, renewing, amending or continuing any individual health insurance policy in this state providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 shall complete any coverage determination with respect to such policy and notify the insured or the insured’s health care provider of its decision not later than forty-five days after a request for such determination is received by the insurer, health care center, hospital service corporation, medical service corporation or other entity. In the case of a denial of coverage, such entity shall notify the insured and the insured’s health care provider of the reasons for such denial. If the reasons for such denial include that the requested service is not medically necessary or is not a covered benefit under such policy, the entity shall (1) notify the insured that such insured may contact the Office of the Healthcare Advocate if the insured believes the insured has been given erroneous information, and (2) provide to such insured the contact information for said office.

(P.A. 99-284, S. 12; P.A. 10-24, S. 1; P.A. 11-19, S. 23.)

History: P.A. 10-24 made technical changes and added requirement for information re Office of the Healthcare Advocate to be provided to insured for certain denials of coverage, effective January 1, 2011; P.A. 11-19 made technical changes.

See Sec. 38a-513a for similar provisions re group policies.

Sec. 38a-483c. Coverage and notice re experimental treatments. Appeals. (a) Each individual health insurance policy delivered, issued for delivery, renewed, amended or continued in this state shall define the extent to which it provides coverage for experimental treatments.

(b) No such health insurance policy may deny a procedure, treatment or the use of any drug as experimental if such procedure, treatment or drug, for the illness or condition being treated, or for the diagnosis for which it is being prescribed, has successfully completed a phase III clinical trial of the federal Food and Drug Administration.

(c) Any person who has been diagnosed with a condition that creates a life expectancy in that person of less than two years and who has been denied an otherwise covered procedure, treatment or drug on the grounds that it is experimental may request an expedited appeal as provided in section 38a-591e and may appeal a denial thereof to the Insurance Commissioner in accordance with the procedures established in section 38a-591g.

(P.A. 99-284, S. 15, 60; P.A. 11-58, S. 81; P.A. 12-145, S. 43.)

History: P.A. 99-284 effective January 1, 2000; P.A. 11-58 amended Subsec. (c) to replace references to Secs. 38a-226c and 38a-478n with “section 38a-591e” and “section 38a-591g”, respectively, and deleted former Subsec. (d) re appeal of a procedure, treatment or drug denied on grounds that such procedure, treatment or drug is experimental, effective July 1, 2011; P.A. 12-145 amended Subsec. (a) to delete “on or after January 1, 2000”, effective June 15, 2012.

See Sec. 38a-513b for similar provisions re group policies.

Sec. 38a-484. (Formerly Sec. 38-168). Policy provisions not to be less favorable than standard. Validity of policy issued in violation of law. (a) No policy provision which is not subject to section 38a-483 shall make a policy, or any portion thereof, less favorable in any respect to the insured or the beneficiary than the provisions thereof which are subject to sections 38a-481 to 38a-488, inclusive.

(b) A policy delivered or issued for delivery to any person in this state in violation of said sections shall be held valid but shall be construed as provided in said sections. When any provision in a policy subject to said sections is in conflict with any provision of said sections, the rights, duties and obligations of the insurer, the insured and the beneficiary shall be governed by the provisions of said sections.

(1949 Rev., S. 6185; 1951, S. 2838d.)

History: Sec. 38-168 transferred to Sec. 38a-484 in 1991.

Sec. 38a-485. (Formerly Sec. 38-169). Copy of application to be part of new policy or to be furnished with renewal. Alteration of application. (a) The insured shall not be bound by any statement made in an application for an individual health insurance policy unless a copy of such application is attached to or endorsed on the policy when issued as a part thereof. If any such policy delivered or issued for delivery to any person in this state is reinstated or renewed, and the insured or the beneficiary or assignee of such policy makes written request to the insurer for a copy of the application, if any, for such reinstatement or renewal, the insurer shall, within fifteen days after the receipt of such request at its home office or any branch office of the insurer, deliver or mail to the person making such request, a copy of such application. If such copy is not so delivered or mailed, the insurer shall be precluded from introducing such application as evidence in any action or proceeding based upon or involving such policy or its reinstatement or renewal.

(b) No alteration of any written application for any such policy shall be made by any person other than the applicant without his written consent, except that insertions may be made by the insurer, for administrative purposes only, in such manner as to indicate clearly that such insertions are not to be ascribed to the applicant.

(c) The falsity of any statement in the application for any policy covered by sections 38a-481 to 38a-488, inclusive, may not bar the right to recovery thereunder unless such false statement materially affected either the acceptance of the risk or the hazard assumed by the insurer.

(1949 Rev., S. 6184; 1951, S. 2839d; P.A. 90-243, S. 75.)

History: P.A. 90-243 added reference to “an individual health insurance” policy; Sec. 38-169 transferred to Sec. 38a-485 in 1991.

Annotation to former section 38-169:

Cited. 214 C. 303.

Sec. 38a-486. (Formerly Sec. 38-170). Certain acts not to operate as waiver of rights. The acknowledgment by any insurer of the receipt of notice given under any individual health insurance policy, or the furnishing of forms for filing proofs of loss, or the acceptance of such proofs, or the investigation of any claim thereunder shall not operate as a waiver of any of the rights of the insurer in defense of any claim arising under such policy.

(1949 Rev., S. 6183; 1951, S. 2840d; P.A. 90-243, S. 76.)

History: P.A. 90-243 added reference to “an individual health insurance” policy; Sec. 38-170 transferred to Sec. 38a-486 in 1991.

Sec. 38a-487. (Formerly Sec. 38-171). Coverage after termination date of policy. If any individual health insurance policy contains a provision establishing, as an age limit or otherwise, a date after which the coverage provided by the policy will not be effective, and if such date falls within a period for which a premium is accepted by the insurer or if the insurer accepts a premium after such date, the coverage provided by the policy will continue in force subject to any right of cancellation until the end of the period for which the premium has been accepted. If the age of the insured has been misstated and if, according to the correct age of the insured, the coverage provided by the policy would not have become effective, or would have ceased prior to the acceptance of such premium or premiums, the liability of the insurer shall be limited to the refund, upon request, of all premiums paid for the period not covered by the policy.

(1951, S. 2841d; P.A. 90-243, S. 77.)

History: P.A. 90-243 added reference to “an individual health insurance” policy; Sec. 38-171 transferred to Sec. 38a-487 in 1991.

Sec. 38a-488. (Formerly Sec. 38-172). Discrimination. Discrimination between individuals of the same class in the amount of premiums or rates charged for any individual health insurance policy, or in the benefits payable thereon, or in any of the terms or conditions of such policy, or in any other manner, is prohibited.

(1949 Rev., S. 6188; 1951, S. 2844d; P.A. 90-243, S. 78.)

History: P.A. 90-243 substituted reference to “individual health insurance” policy for reference to policies under Secs. 38-165 to 38-172; Sec. 38-172 transferred to Sec. 38a-488 in 1991.

See Sec. 38a-446 re prohibition against discrimination in favor of individuals by life insurance companies.

See Sec. 38a-447 re prohibition of discrimination against persons on basis of race.

See Sec. 38a-816 re unfair practices.

Sec. 38a-488a. Mandatory coverage for the diagnosis and treatment of mental or nervous conditions. Exceptions. Benefits payable re type of provider or facility. State’s claim against proceeds. (a) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide benefits for the diagnosis and treatment of mental or nervous conditions. For the purposes of this section, “mental or nervous conditions” means mental disorders, as defined in the most recent edition of the American Psychiatric Association’s “Diagnostic and Statistical Manual of Mental Disorders”. “Mental or nervous conditions” does not include (1) mental retardation, (2) learning disorders, (3) motor skills disorders, (4) communication disorders, (5) caffeine-related disorders, (6) relational problems, and (7) additional conditions that may be a focus of clinical attention, that are not otherwise defined as mental disorders in the most recent edition of the American Psychiatric Association’s “Diagnostic and Statistical Manual of Mental Disorders”.

(b) No such policy shall establish any terms, conditions or benefits that place a greater financial burden on an insured for access to diagnosis or treatment of mental or nervous conditions than for diagnosis or treatment of medical, surgical or other physical health conditions.

(c) In the case of benefits payable for the services of a licensed physician, such benefits shall be payable for the same services when such services are lawfully rendered by a psychologist licensed under the provisions of chapter 383 or by such a licensed psychologist in a licensed hospital or clinic.

(d) In the case of benefits payable for the services of a licensed physician or psychologist, such benefits shall be payable for the same services when such services are rendered by:

(1) A clinical social worker who is licensed under the provisions of chapter 383b and who has passed the clinical examination of the American Association of State Social Work Boards and has completed at least two thousand hours of post-master’s social work experience in a nonprofit agency qualifying as a tax-exempt organization under Section 501(c) of the Internal Revenue Code of 1986 or any subsequent corresponding internal revenue code of the United States, as from time to time amended, in a municipal, state or federal agency or in an institution licensed by the Department of Public Health under section 19a-490;

(2) A social worker who was certified as an independent social worker under the provisions of chapter 383b prior to October 1, 1990;

(3) A licensed marital and family therapist who has completed at least two thousand hours of post-master’s marriage and family therapy work experience in a nonprofit agency qualifying as a tax-exempt organization under Section 501(c) of the Internal Revenue Code of 1986 or any subsequent corresponding internal revenue code of the United States, as from time to time amended, in a municipal, state or federal agency or in an institution licensed by the Department of Public Health under section 19a-490;

(4) A marital and family therapist who was certified under the provisions of chapter 383a prior to October 1, 1992;

(5) A licensed alcohol and drug counselor, as defined in section 20-74s, or a certified alcohol and drug counselor, as defined in section 20-74s; or

(6) A licensed professional counselor.

(e) For purposes of this section, the term “covered expenses” means the usual, customary and reasonable charges for treatment deemed necessary under generally accepted medical standards, except that in the case of a managed care plan, as defined in section 38a-478, “covered expenses” means the payments agreed upon in the contract between a managed care organization, as defined in section 38a-478, and a provider, as defined in section 38a-478.

(f) (1) In the case of benefits payable for the services of a licensed physician, such benefits shall be payable for (A) services rendered in a child guidance clinic or residential treatment facility by a person with a master’s degree in social work or by a person with a master’s degree in marriage and family therapy under the supervision of a psychiatrist, physician, licensed marital and family therapist, or licensed clinical social worker who is eligible for reimbursement under subdivisions (1) to (4), inclusive, of subsection (d) of this section; (B) services rendered in a residential treatment facility by a licensed or certified alcohol and drug counselor who is eligible for reimbursement under subdivision (5) of subsection (d) of this section; or (C) services rendered in a residential treatment facility by a licensed professional counselor who is eligible for reimbursement under subdivision (6) of subsection (d) of this section.

(2) In the case of benefits payable for the services of a licensed psychologist under subsection (d) of this section, such benefits shall be payable for (A) services rendered in a child guidance clinic or residential treatment facility by a person with a master’s degree in social work or by a person with a master’s degree in marriage and family therapy under the supervision of such licensed psychologist, licensed marital and family therapist, or licensed clinical social worker who is eligible for reimbursement under subdivisions (1) to (4), inclusive, of subsection (d) of this section; (B) services rendered in a residential treatment facility by a licensed or certified alcohol and drug counselor who is eligible for reimbursement under subdivision (5) of subsection (d) of this section; or (C) services rendered in a residential treatment facility by a licensed professional counselor who is eligible for reimbursement under subdivision (6) of subsection (d) of this section.

(g) In the case of benefits payable for the service of a licensed physician practicing as a psychiatrist or a licensed psychologist, under subsection (d) of this section, such benefits shall be payable for outpatient services rendered (1) in a nonprofit community mental health center, as defined by the Department of Mental Health and Addiction Services, in a nonprofit licensed adult psychiatric clinic operated by an accredited hospital or in a residential treatment facility; (2) under the supervision of a licensed physician practicing as a psychiatrist, a licensed psychologist, a licensed marital and family therapist, a licensed clinical social worker, a licensed or certified alcohol and drug counselor or a licensed professional counselor who is eligible for reimbursement under subdivisions (1) to (6), inclusive, of subsection (d) of this section; and (3) within the scope of the license issued to the center or clinic by the Department of Public Health or to the residential treatment facility by the Department of Children and Families.

(h) Except in the case of emergency services or in the case of services for which an individual has been referred by a physician affiliated with a health care center, nothing in this section shall be construed to require a health care center to provide benefits under this section through facilities that are not affiliated with the health care center.

(i) In the case of any person admitted to a state institution or facility administered by the Department of Mental Health and Addiction Services, Department of Public Health, Department of Children and Families or the Department of Developmental Services, the state shall have a lien upon the proceeds of any coverage available to such person or a legally liable relative of such person under the terms of this section, to the extent of the per capita cost of such person’s care. Except in the case of emergency services, the provisions of this subsection shall not apply to coverage provided under a managed care plan, as defined in section 38a-478.

(June 18 Sp. Sess. P.A. 97-8, S. 63, 88; P.A. 99-284, S. 27, 60; P.A. 00-135, S. 10, 21; P.A. 02-24, S. 6; P.A. 07-73, S. 2(a); P.A. 12-145, S. 45.)

History: June 18 Sp. Sess. P.A. 97-8 effective July 1, 1997; P.A. 99-284 rewrote Subsec. (a) and referenced Subdivs. (1), (2), (4), (11) and (12) of Sec. 38a-469, deleted reference to biologically-based mental or nervous conditions and definition thereof and replaced with provision for coverage of the diagnosis and treatment of mental or nervous conditions, and defined “mental or nervous conditions”, added new Subsec. (b) re prohibition on terms, conditions or benefits that place a greater financial burden on insured re mental or nervous conditions than for other conditions, added new Subsec. (c) re benefits payable when rendered by a psychologist, added new Subsec. (d) re benefits payable for enumerated providers, added new Subsec. (e) to define “covered expenses”, added new Subsec. (f) re benefits payable for services rendered in certain facilities, added new Subsec. (g) re certain outpatient benefits, added new Subsec. (h) re benefits provided by a health care center, and added new Subsec. (i) re state liens against certain coverage proceeds, effective January 1, 2000; P.A. 00-135 reorganized section and added provisions re licensed professional counselors, effective May 26, 2000; P.A. 02-24 deleted “the” re “post-master’s social work experience” in Subsec. (d)(1) and (3); pursuant to P.A. 07-73 “Department of Mental Retardation” was changed editorially by the Revisors to “Department of Developmental Services”, effective October 1, 2007; P.A. 12-145 amended Subsec. (a) to delete “on or after January 1, 2000”, effective June 15, 2012.

See Sec. 38a-514 for similar provisions re group policies.

Sec. 38a-488b. Coverage for autism spectrum disorder therapies. Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 that is delivered, issued for delivery, renewed, amended or continued in this state on or after January 1, 2009, shall provide coverage for physical therapy, speech therapy and occupational therapy services for the treatment of autism spectrum disorder, as set forth in the most recent edition of the American Psychiatric Association’s “Diagnostic and Statistical Manual of Mental Disorders”, to the extent such services are a covered benefit for other diseases and conditions under such policy.

(P.A. 08-132, S. 1; P.A. 11-4, S. 6.)

History: P.A. 08-132 effective January 1, 2009; P.A. 11-4 substituted “autism spectrum disorder” for “autism spectrum disorders”, effective May 9, 2011.

See Sec. 38a-514b for provisions re group policies.

Sec. 38a-489. (Formerly Sec. 38-174e). Continuation of coverage of mentally or physically handicapped children. (a) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469, delivered, issued for delivery, renewed, amended or continued in this state more than one hundred twenty days after July 1, 1971, that provides that coverage of a dependent child shall terminate upon attainment of the limiting age for dependent children specified in the policy shall also provide in substance that attainment of the limiting age shall not operate to terminate the coverage of the child if at such date the child is and continues thereafter to be both (1) incapable of self-sustaining employment by reason of mental or physical handicap, as certified by the child’s physician on a form provided by the insurer, hospital or medical service corporation or health care center, and (2) chiefly dependent upon the policyholder or subscriber for support and maintenance.

(b) Proof of the incapacity and dependency shall be furnished to the insurer, hospital or medical service plan corporation or health care center by the policyholder or subscriber within thirty-one days of the child’s attainment of the limiting age. The insurer, corporation or health care center may at any time require proof of the child’s continuing incapacity and dependency. After a period of two years has elapsed following the child’s attainment of the limiting age the insurer, corporation or health care center may require periodic proof of the child’s continuing incapacity and dependency but in no case more frequently than once every year.

(1971, P.A. 408, S. 1, 2; P.A. 87-207, S. 1; P.A. 90-243, S. 79; P.A. 11-19, S. 33.)

History: P.A. 87-207 amended Subsecs. (a) and (b) to provide that for individual and group policies the continuation rights for children are applicable if the child is incapable of employment by reason of mental or physical handicap which has been certified by the child’s physician; P.A. 90-243 substituted reference to “health insurance policy” for reference to hospital or medical expense policies and contracts, divided former Subsec. (a) into Subsecs. (a) and (b), added a reference to “health care center” and deleted former Subsec. (b) re group policies; Sec. 38-174e transferred to Sec. 38a-489 in 1991; P.A. 11-19 inserted “renewed, amended or continued” and made technical changes in Subsec. (a), effective January 1, 2012.

See Sec. 38a-515 for similar provisions re group policies.

See Sec. 38a-538 re conversion and extension rights of group members and re liability of group employers.

Sec. 38a-490. (Formerly Sec. 38-174g). Coverage for newly born children. Notification to insurer. (a) Each individual health insurance policy delivered, issued for delivery, renewed, amended or continued in this state providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469 for a family member of the insured or subscriber shall, as to such family member’s coverage, also provide that the health insurance benefits applicable for children shall be payable with respect to a newly born child of the insured or subscriber from the moment of birth.

(b) Coverage for such newly born child shall consist of coverage for injury and sickness including necessary care and treatment of medically diagnosed congenital defects and birth abnormalities within the limits of the policy.

(c) If payment of a specific premium or subscription fee is required to provide coverage for a child, the policy or contract may require that notification of birth of such newly born child and payment of the required premium or fees shall be furnished to the insurer, hospital service corporation, medical service corporation or health care center not later than sixty-one days after the date of birth in order to continue coverage beyond such sixty-one-day period, provided failure to furnish such notice or pay such premium or fees shall not prejudice any claim originating within such sixty-one-day period.

(P.A. 74-6, S. 1–4; P.A. 90-243, S. 80; P.A. 11-19, S. 35; 11-171, S. 3; P.A. 12-145, S. 12.)

History: P.A. 90-243 substituted references to “health insurance policies” for references to hospital and medical expense policies and contracts, specified applicability to individual policies only, and applied provisions to “health care centers”; Sec. 38-174g transferred to Sec. 38a-490 in 1991; P.A. 11-19 inserted “delivered, issued for delivery, renewed, amended or continued in this state” and made a technical change in Subsec. (a), made technical changes in Subsec. (c), and deleted former Subsec. (d) re application of section to policies delivered or issued for delivery on or after October 1, 1974, or amended or renewed, effective January 1, 2012; P.A. 11-171 inserted “delivered, issued for delivery, renewed, amended or continued in this state” and made a technical change in Subsec. (a), increased time period for insured to notify insurer of birth of child and pay required premium or fee from 31 days to 61 days after birth and made technical changes in Subsec. (c), and deleted former Subsec. (d) re application of section to policies delivered or issued for delivery on or after October 1, 1974, or amended or renewed, effective January 1, 2012; P.A. 12-145 made a technical change in Subsec. (a), effective June 15, 2012.

See Sec. 38a-516 for similar provisions re group policies.

See Sec. 38a-538 re conversion and extension rights of group members and re liability of group employers.

Sec. 38a-490a. Coverage for birth-to-three program. (a) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for medically necessary early intervention services provided as part of an individualized family service plan pursuant to section 17a-248e. Such policy shall provide coverage for such services provided by qualified personnel, as defined in section 17a-248, for a child from birth until the child’s third birthday.

(b) No such policy shall impose a coinsurance, copayment, deductible or other out-of-pocket expense for such services, except that a high deductible plan, as that term is used in subsection (f) of section 38a-493, shall not be subject to the deductible limits set forth in this section.

(c) Such policy shall provide a maximum benefit of six thousand four hundred dollars per child per year and an aggregate benefit of nineteen thousand two hundred dollars per child over the total three-year period.

(d) No payment made under this section shall (1) be applied by the insurer, health care center or plan administrator against or result in a loss of benefits due to any maximum lifetime or annual limits specified in the policy, (2) adversely affect the availability of health insurance to the child, the child’s parent or the child’s family members insured under any such policy, or (3) be a reason for the insurer, health care center or plan administrator to rescind or cancel such policy. Payments made under this section shall not be treated differently than other claim experience for purposes of premium rating.

(P.A. 96-185, S. 6, 16; June 30 Sp. Sess. P.A. 03-3, S. 7; Sept. Sp. Sess. P.A. 09-3, S. 46; P.A. 11-44, S. 147; P.A. 12-44, S. 1.)

History: P.A. 96-185 effective July 1, 1996; June 30 Sp. Sess. P.A. 03-3 deleted provision re coverage for at least $5,000 annually, added Subdivs. (1) and (2) re coverage and benefits to be provided by policy and made technical changes, effective August 20, 2003; Sept. Sp. Sess. P.A. 09-3 amended Subdiv. (2) by increasing per child per year benefit from $3,200 to $6,400 and by increasing 3-year per child aggregate benefit from $9,600 to $19,200, effective October 6, 2009; P.A. 11-44 added provision prohibiting out-of-pocket expenses with exception for high deductible plans, deleted Subdiv. (1) and (2) designators and made technical changes, effective January 1, 2012; P.A. 12-44 designated existing provisions as Subsecs. (a) to (d), amended Subsec. (a) to add “amended or continued” and delete “on or after July 1, 1996”, amended Subsec. (d) to add provisions re restrictions on treatment of payment, and made technical changes, effective July 1, 2012.

See Sec. 38a-516a for similar provisions re group policies.

Sec. 38a-490b. Coverage for hearing aids for children twelve and under. Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for hearing aids for children twelve years of age or younger. Such hearing aids shall be considered durable medical equipment under the policy and the policy may limit the hearing aid benefit to one thousand dollars within a twenty-four-month period.

(P.A. 01-171, S. 15; P.A. 12-145, S. 47.)

History: P.A. 12-145 deleted “on or after October 1, 2001”, effective June 15, 2012.

See Sec. 38a-516b for similar provisions re group policies.

Sec. 38a-490c. Coverage for craniofacial disorders. Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state on or after October 1, 2003, shall provide coverage for medically necessary orthodontic processes and appliances for the treatment of craniofacial disorders for individuals eighteen years of age or younger if such processes and appliances are prescribed by a craniofacial team recognized by the American Cleft Palate-Craniofacial Association, except that no coverage shall be required for cosmetic surgery.

(P.A. 03-37, S. 1.)

See Sec. 38a-516c for similar provisions re group policies.

Sec. 38a-490d. Mandatory coverage for blood lead screening and risk assessment. Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state on or after January 1, 2009, shall provide coverage for blood lead screening and risk assessments ordered by a primary care provider pursuant to section 19a-111g.

(June Sp. Sess. P.A. 07-2, S. 51.)

History: June Sp. Sess. P.A. 07-2 effective January 1, 2009.

Sec. 38a-491. (Formerly Sec. 38-174h). Coverage for services performed by dentists in certain instances. Whenever the term “physician” or “doctor” is used in any individual health insurance policy delivered, issued for delivery or renewed in this state on or after October 1, 1975, it shall be deemed to include persons licensed, under the provisions of chapter 379, to engage in the practice of dentistry or dental medicine, when benefits under such policy or contract for care, treatment or services rendered or procedures performed by such person would be payable if rendered or performed by a person licensed under chapter 370.

(P.A. 75-449; P.A. 90-243, S. 81.)

History: P.A. 90-243 substituted reference to “health insurance policy” for reference to hospital and medical expense policies and contracts and specified applicability to individual policies only; Sec. 38-174h transferred to Sec. 38a-491 in 1991.

See Sec. 38a-517 for similar provisions re group policies.

Sec. 38a-491a. Coverage for in-patient, outpatient or one-day dental services in certain instances. (a) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for general anesthesia, nursing and related hospital services provided in conjunction with in-patient, outpatient or one-day dental services if the following conditions are met:

(1) The anesthesia, nursing and related hospital services are deemed medically necessary by the treating dentist or oral surgeon and the patient’s primary care physician in accordance with the health insurance policy’s requirements for prior authorization of services; and

(2) The patient is either (A) determined by a licensed dentist, in conjunction with a licensed physician who specializes in primary care, to have a dental condition of significant dental complexity that it requires certain dental procedures to be performed in a hospital, or (B) a person who has a developmental disability, as determined by a licensed physician who specializes in primary care, that places the person at serious risk.

(b) The expense of such anesthesia, nursing and related hospital services shall be deemed a medical expense under such health insurance policy and shall not be subject to any limits on dental benefits under such policy.

(P.A. 99-284, S. 40, 60; P.A. 00-135, S. 13, 21; P.A. 03-58, S. 1; P.A. 10-5, S. 20.)

History: P.A. 99-284 effective January 1, 2000; P.A. 00-135 added outpatient or one-day dental services, effective May 26, 2000; P.A. 03-58 divided existing provisions into Subsecs. (a) and (b) and deleted “a child under the age of four who is” in Subsec. (a)(2)(A); P.A. 10-5 made technical changes in Subsec. (a), effective January 1, 2011.

See Sec. 38a-517a for similar provisions re group policies.

Sec. 38a-491b. Assignment of benefits to a dentist or oral surgeon. No insurer, health care center, hospital service corporation, medical service corporation or other entity delivering, issuing for delivery, renewing, continuing or amending any individual health insurance policy in this state providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469, and no dental services plan offering or administering dental services, may refuse to accept or make reimbursement pursuant to an assignment of benefits made to a dentist or oral surgeon by an insured, subscriber or enrollee, provided (1) the dentist or oral surgeon charges the insured, subscriber or enrollee no more for services than the dentist or surgeon charges uninsured patients for the same services, and (2) the dentist or oral surgeon allows the insurer, health care center, corporation or entity to review the records related to the insured, subscriber or enrollee during regular business hours. The insurer, health care center, corporation or entity shall give the dentist or oral surgeon at least forty-eight hours’ notice prior to such review. As used in this section, “assignment of benefits” means the transfer of dental care coverage reimbursement benefits or other rights under an insurance policy, subscription contract or dental services plan by an insured, subscriber or enrollee to a dentist or oral surgeon.

(P.A. 00-33, S. 1, 3; P.A. 11-19, S. 25.)

History: P.A. 00-33 effective July 1, 2000; P.A. 11-19 made technical changes.

See Sec. 38a-517b for similar provisions re group policies.

Sec. 38a-492. (Formerly Sec. 38-174i). Coverage for accidental ingestion or consumption of controlled drugs. Benefits prescribed. No individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10) and (11) of section 38a-469 shall be delivered, issued for delivery or renewed in this state, or amended to substantially alter or change benefits or coverage, on or after July 1, 1975, unless persons covered under such policy will be eligible for benefits for expenses of emergency medical care arising from accidental ingestion or consumption of a controlled drug, as defined by subdivision (8) of section 21a-240, which are at least equal to the following minimum requirements: (1) In the case of benefits based upon confinement as an inpatient in a hospital, whether or not operated by the state, the period of confinement for which benefits shall be payable shall be at least thirty days in any calendar year. (2) For covered expenses incurred by the insured while other than an inpatient in a hospital, benefits shall be available for such expenses during any calendar year up to a maximum of five hundred dollars. For purposes of this section, the term “covered expenses” means the reasonable charges for treatment deemed necessary under generally accepted medical standards.

(P.A. 75-512, S. 1, 2; P.A. 85-613, S. 73, 154; P.A. 90-243, S. 82.)

History: P.A. 85-613 made technical change; P.A. 90-243 substituted reference to “health insurance policy” for reference to hospital and medical expense policies or contracts, specified applicability to individual policies only, and replaced alphabetic Subdiv. indicators with numeric ones; Sec. 38-174i transferred to Sec. 38a-492 in 1991; (Revisor’s note: In 2001, a reference to “subsection (a) of” Sec. 38a-469 was deleted editorially by the Revisors for accuracy).

See Sec. 38a-518 for similar provisions re group policies.

Sec. 38a-492a. Mandatory coverage for hypodermic needles and syringes. Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469, delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for hypodermic needles or syringes prescribed by a prescribing practitioner, as defined in subdivision (22) of section 20-571, for the purpose of administering medications for medical conditions, provided such medications are covered under the policy. Such benefits shall be subject to any policy provisions that apply to other services covered by such policy.

(P.A. 92-185, S. 4, 6; P.A. 95-264, S. 62; P.A. 11-19, S. 37.)

History: P.A. 95-264 substituted “prescribing practitioner” for “licensed practitioner” (Revisor’s note: The reference to “prescribing practitioner, as defined in subdivision (21) of ...” was changed editorially by the Revisors to “prescribing practitioner, as defined in subdivision (22) of ...”); P.A. 11-19 inserted “amended or continued” and made technical changes, effective January 1, 2012.

See Sec. 38a-518a for similar provisions re group policies.

Sec. 38a-492b. Coverage for off-label drug prescriptions. (a) Each individual health insurance policy delivered, issued for delivery, renewed, amended or continued in this state, that provides coverage for prescribed drugs approved by the federal Food and Drug Administration for treatment of certain types of cancer or disabling or life-threatening chronic diseases, shall not exclude coverage of any such drug on the basis that such drug has been prescribed for the treatment of a type of cancer or a disabling or life-threatening chronic disease for which the drug has not been approved by the federal Food and Drug Administration, provided the drug is recognized for treatment of the specific type of cancer or a disabling or life-threatening chronic disease for which the drug has been prescribed in one of the following established reference compendia: (1) The U.S. Pharmacopoeia Drug Information Guide for the Health Care Professional (USP DI); (2) The American Medical Association’s Drug Evaluations (AMA DE); or (3) The American Society of Hospital Pharmacists’ American Hospital Formulary Service Drug Information (AHFS-DI).

(b) Nothing in subsection (a) of this section shall be construed to require coverage for any experimental or investigational drugs or any drug which the federal Food and Drug Administration has determined to be contraindicated for treatment of the specific type of cancer or disabling or life-threatening chronic disease for which the drug has been prescribed.

(c) Except as specified, nothing in this section shall be construed to create, impair, limit or modify authority to provide reimbursement for drugs used in the treatment of any other disease or condition.

(P.A. 94-49, S. 2; P.A. 11-19, S. 39; 11-172, S. 15.)

History: P.A. 11-19 amended Subsec. (a) to add “amended or continued” and make technical changes, effective January 1, 2012; P.A. 11-172 amended Subsec. (a) to add “amended or continued”, add provisions re disabling or life-threatening chronic disease and make technical changes, amended Subsec. (b) to add provision re disabling or life-threatening chronic disease and amended Subsec. (c) to add “Except as specified”, effective January 1, 2012.

See Sec. 38a-518b for similar provisions re group policies.

Sec. 38a-492c. Coverage for low protein modified food products, amino acid modified preparations and specialized formulas. (a) For purposes of this section:

(1) “Inherited metabolic disease” includes (A) a disease for which newborn screening is required under section 19a-55; and (B) cystic fibrosis.

(2) “Low protein modified food product” means a product formulated to have less than one gram of protein per serving and intended for the dietary treatment of an inherited metabolic disease under the direction of a physician.

(3) “Amino acid modified preparation” means a product intended for the dietary treatment of an inherited metabolic disease under the direction of a physician.

(4) “Specialized formula” means a nutritional formula for children up to age twelve that is exempt from the general requirements for nutritional labeling under the statutory and regulatory guidelines of the federal Food and Drug Administration and is intended for use solely under medical supervision in the dietary management of specific diseases.

(b) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for amino acid modified preparations and low protein modified food products for the treatment of inherited metabolic diseases if the amino acid modified preparations or low protein modified food products are prescribed for the therapeutic treatment of inherited metabolic diseases and are administered under the direction of a physician.

(c) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for specialized formulas when such specialized formulas are medically necessary for the treatment of a disease or condition and are administered under the direction of a physician.

(d) Such policy shall provide coverage for such preparations, food products and formulas on the same basis as outpatient prescription drugs.

(P.A. 97-167, S. 1; P.A. 01-101, S. 1; P.A. 04-173, S. 1: P.A. 07-197, S. 1; P.A. 12-145, S. 54.)

History: P.A. 01-101 defined, in new Subsec. (a)(4), and added coverage, in new Subsec. (c), for specialized formula; P.A. 04-173 amended Subsec. (a)(1) and (4) to redefine “inherited metabolic disease” to include cystic fibrosis and redefine “specialized formula” to include formula for children up to age 8, instead of age 3, and added Subsec. (d) to require coverage on the same basis as for outpatient prescription drugs; P.A. 07-197 amended Subsec. (a)(4) to redefine “specialized formula” to include formula for children up to age 12, instead of age 8, and amended Subsec. (c) to require coverage to be applicable to policies delivered, issued for delivery or renewed in this state on or after October 1, 2007; P.A. 12-145 amended Subsecs. (b) and (c) to delete references to Sec. 38a-469(6), add “amended or continued” re policy and delete 1997 and 2007 date references, effective January 1, 2013.

See Sec. 38a-518c for similar provisions re group policies.

Sec. 38a-492d. Mandatory coverage for diabetes testing and treatment. (a) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery or renewed in this state on or after October 1, 1997, shall provide coverage for laboratory and diagnostic tests for all types of diabetes.

(b) Notwithstanding the provisions of section 38a-492a, each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery or renewed in this state on or after October 1, 1997, shall provide medically necessary coverage for the treatment of insulin-dependent diabetes, insulin-using diabetes, gestational diabetes and non-insulin-using diabetes. Such coverage shall include medically necessary equipment, in accordance with the insured person’s treatment plan, drugs and supplies prescribed by a prescribing practitioner, as defined in section 20-571.

(P.A. 97-268, S. 4.)

See Sec. 38a-518d for similar provisions re group policies.

Sec. 38a-492e. Mandatory coverage for diabetes outpatient self-management training. (a) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed or continued in this state on or after January 1, 2000, shall provide coverage for outpatient self-management training for the treatment of insulin-dependent diabetes, insulin-using diabetes, gestational diabetes and non-insulin-using diabetes if the training is prescribed by a licensed health care professional who has appropriate state licensing authority to prescribe such training. As used in this section, “outpatient self-management training” includes, but is not limited to, education and medical nutrition therapy. Diabetes self-management training shall be provided by a certified, registered or licensed health care professional trained in the care and management of diabetes and authorized to provide such care within the scope of the professional’s practice.

(b) Benefits shall cover: (1) Initial training visits provided to an individual after the individual is initially diagnosed with diabetes that is medically necessary for the care and management of diabetes, including, but not limited to, counseling in nutrition and the proper use of equipment and supplies for the treatment of diabetes, totaling a maximum of ten hours; (2) training and education that is medically necessary as a result of a subsequent diagnosis by a physician of a significant change in the individual’s symptoms or condition which requires modification of the individual’s program of self-management of diabetes, totaling a maximum of four hours; and (3) training and education that is medically necessary because of the development of new techniques and treatment for diabetes totaling a maximum of four hours.

(c) Benefits provided pursuant to this section shall be subject to the same terms and conditions applicable to all other benefits under such policies.

(P.A. 99-284, S. 43, 60.)

History: P.A. 99-284 effective January 1, 2000.

See Sec. 38a-518e for similar provisions re group policies.

Sec. 38a-492f. Mandatory coverage for certain prescription drugs removed from formulary. Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state that provides coverage for outpatient prescription drugs shall not deny coverage for an insured for any drug that the insurer removes from its list of covered drugs, or otherwise ceases to provide coverage for, if (1) the insured was using the drug for the treatment of a chronic illness prior to the removal or cessation of coverage, (2) the insured was covered under the policy for the drug prior to the removal or cessation of coverage, and (3) the insured’s attending health care provider states in writing, after the removal or cessation of coverage, that the drug is medically necessary and lists the reasons why the drug is more medically beneficial than the drugs on the list of covered drugs. Such benefits shall be subject to the same terms and conditions applicable to all other benefits under such policies.

(P.A. 99-284, S. 37, 60; P.A. 12-145, S. 56.)

History: P.A. 99-284 effective January 1, 2000; P.A. 12-145 added “amended” re policy and deleted “on or after January 1, 2000”, effective January 1, 2013.

See Sec. 38a-518f for similar provisions re group policies.

Sec. 38a-492g. Mandatory coverage for prostate cancer screening and treatment. Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for:

(1) Laboratory and diagnostic tests, including, but not limited to, prostate specific antigen (PSA) tests, to screen for prostate cancer for men who are symptomatic or whose biological father or brother has been diagnosed with prostate cancer, and for all men fifty years of age or older; and

(2) The treatment of prostate cancer, provided such treatment is medically necessary and in accordance with guidelines established by the National Comprehensive Cancer Network, the American Cancer Society or the American Society of Clinical Oncology.

(P.A. 99-284, S. 45, 60; P.A. 11-225, S. 1.)

History: P.A. 99-284 effective January 1, 2000; P.A. 11-225 inserted “amended” re policy, designated existing provision re screening coverage as Subdiv. (1), added Subdiv. (2) re treatment coverage, and made technical changes, effective January 1, 2012.

See Sec. 38a-518g for similar provisions re group policies.

Sec. 38a-492h. Mandatory coverage for certain Lyme disease treatments. Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed or continued in this state on or after January 1, 2000, shall provide coverage for Lyme disease treatment including not less than thirty days of intravenous antibiotic therapy, sixty days of oral antibiotic therapy, or both, and shall provide further treatment if recommended by a board certified rheumatologist, infectious disease specialist or neurologist licensed in accordance with chapter 370 or who is licensed in another state or jurisdiction whose requirements for practicing in such capacity are substantially similar to or higher than those of this state.

(P.A. 99-284, S. 47, 60; June Sp. Sess. P.A. 99-2, S. 2, 72.)

History: P.A. 99-284 effective January 1, 2000; June Sp. Sess. P.A. 99-2 added specialists “licensed in another state or jurisdiction whose requirements for practicing in such capacity are substantially similar to or higher than those of this state”, effective January 1, 2000.

See Sec. 38a-518h for similar provisions re group policies.

Sec. 38a-492i. Mandatory coverage for pain management. (a) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (10), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide access to a pain management specialist and coverage for pain treatment ordered by such specialist that may include all means medically necessary to make a diagnosis and develop a treatment plan including the use of necessary medications and procedures.

(b) (1) No such policy that provides coverage for prescription drugs shall require an insured to use, prior to using a brand name prescription drug prescribed by a licensed physician for pain treatment, any alternative brand name prescription drugs or over-the-counter drugs.

(2) Such policy may require an insured to use, prior to using a brand name prescription drug prescribed by a licensed physician for pain treatment, a therapeutically equivalent generic drug.

(c) As used in this section, “pain” means a sensation in which a person experiences severe discomfort, distress or suffering due to provocation of sensory nerves, and “pain management specialist” means a physician who is credentialed by the American Academy of Pain Management or who is a board-certified anesthesiologist, physiatrist, neurologist, oncologist or radiation oncologist with additional training in pain management.

(P.A. 00-216, S. 18, 28; P.A. 11-169, S. 1; P.A. 12-197, S. 20.)

History: P.A. 00-216 effective January 1, 2001; P.A. 11-169 designated existing provisions as Subsecs. (a) and (c), added Subsec. (b) prohibiting insurers from requiring insured to use alternative brand name prescription drugs or over-the-counter drugs prior to using brand name prescription drug prescribed for pain treatment, and made technical changes, effective January 1, 2012; P.A. 12-197 amended Subsec. (c) by adding physiatrist to definition of “pain management specialist”, effective June 15, 2012.

See Sec. 38a-518i re group health insurance coverage for pain management.

Sec. 38a-492j. Mandatory coverage for ostomy-related supplies. Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state that provides coverage for ostomy surgery shall include coverage, up to two thousand five hundred dollars annually, for medically necessary appliances and supplies relating to an ostomy including, but not limited to, collection devices, irrigation equipment and supplies, skin barriers and skin protectors. As used in this section, “ostomy” includes colostomy, ileostomy and urostomy. Payments under this section shall not be applied to any policy maximums for durable medical equipment. Nothing in this section shall be deemed to decrease policy benefits in excess of the limits in this section.

(P.A. 00-63, S. 1; P.A. 10-5, S. 21; P.A. 11-204, S. 1.)

History: P.A. 10-5 made technical changes, effective January 1, 2011; P.A. 11-204 increased coverage cap from $1,000 to $2,500 annually, effective January 1, 2012.

See Sec. 38a-518j for similar provisions re group policies.

Sec. 38a-492k. Mandatory coverage for colorectal cancer screening. (a) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state shall provide coverage for colorectal cancer screening, including, but not limited to, (1) an annual fecal occult blood test, and (2) colonoscopy, flexible sigmoidoscopy or radiologic imaging, in accordance with the recommendations established by the American Cancer Society, based on the ages, family histories and frequencies provided in the recommendations. Except as specified in subsection (b) of this section, benefits under this section shall be subject to the same terms and conditions applicable to all other benefits under such policies.

(b) No such policy shall impose:

(1) A deductible for a procedure that a physician initially undertakes as a screening colonoscopy or a screening sigmoidoscopy; or

(2) A coinsurance, copayment, deductible or other out-of-pocket expense for any additional colonoscopy ordered in a policy year by a physician for an insured. The provisions of this subdivision shall not apply to a high deductible health plan as that term is used in subsection (f) of section 38a-493.

(P.A. 01-171, S. 20; P.A. 11-83, S. 1; P.A. 12-61, S. 1; 12-190, S. 1.)

History: P.A. 11-83 designated existing provisions as Subsec. (a) and amended same to insert reference to American College of Radiology, add exception re Subsec. (b) and make a technical change, and added Subsec. (b) prohibiting out-of-pocket expense for additional colonoscopy ordered by physician in a policy year, effective January 1, 2012; P.A. 12-61 amended Subsec. (a) to delete “American College of Gastroenterology” and “American College of Radiology” re recommendations for colorectal cancer screening, effective January 1, 2013; P.A. 12-190 amended Subsec. (b) to redesignate existing provisions as Subdiv. (2) and make conforming changes therein, and add Subdiv. (1) re deductible for procedure initially undertaken as screening colonoscopy or screening sigmoidoscopy, effective January 1, 2013.

See Sec. 38a-472i for payment amount for professional services component of covered colonoscopy or endoscopy services.

See Sec. 38a-518k for similar provisions re group policies.

Sec. 38a-492l. Mandatory coverage for neuropsychological testing for children diagnosed with cancer. Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state on or after October 1, 2006, shall provide coverage without prior authorization for each child diagnosed with cancer on or after January 1, 2000, for neuropsychological testing ordered by a licensed physician, to assess the extent of any cognitive or developmental delays in such child due to chemotherapy or radiation treatment.

(P.A. 06-131, S. 2.)

See Sec. 38a-516d for similar provisions re group policies.

Sec. 38a-492m. Mandatory coverage for certain renewals of prescription eye drops. Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state on or after January 1, 2010, that provides coverage for prescription eye drops, shall not deny coverage for a renewal of prescription eye drops when (1) the renewal is requested by the insured less than thirty days from the later of (A) the date the original prescription was distributed to the insured, or (B) the date the last renewal of such prescription was distributed to the insured, and (2) the prescribing physician indicates on the original prescription that additional quantities are needed and the renewal requested by the insured does not exceed the number of additional quantities needed.

(P.A. 09-136, S. 1.)

History: P.A. 09-136 effective January 1, 2010.

See Sec. 38a-518l for similar provisions re group policies.

Sec. 38a-492n. Mandatory coverage for certain wound-care supplies. Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 that is delivered, issued for delivery, renewed, amended or continued in this state on or after January 1, 2010, shall provide coverage for wound-care supplies that are medically necessary for the treatment of epidermolysis bullosa and are administered under the direction of a physician.

(P.A. 09-51, S. 1.)

History: P.A. 09-51 effective January 1, 2010.

See Sec. 38a-518m for similar provisions re group policies.

Sec. 38a-492o. Mandatory coverage for bone marrow testing. (a) Subject to the provisions of subsection (b) of this section, each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state shall provide coverage for expenses arising from human leukocyte antigen testing, also referred to as histocompatibility locus antigen testing, for A, B and DR antigens for utilization in bone marrow transplantation.

(b) No such policy shall impose a coinsurance, copayment, deductible or other out-of-pocket expense for such testing in excess of twenty per cent of the cost for such testing per year. The provisions of this subsection shall not apply to a high deductible health plan as that term is used in subsection (f) of section 38a-493.

(c) Such policy shall:

(1) Require that such testing be performed in a facility (A) accredited by the American Society for Histocompatibility and Immunogenetics, or its successor, and (B) certified under the Clinical Laboratory Improvement Act of 1967, 42 USC Section 263a, as amended from time to time; and

(2) Limit coverage to individuals who, at the time of such testing, complete and sign an informed consent form that also authorizes the results of the test to be used for participation in the National Marrow Donor Program.

(d) Such policy may limit such coverage to a lifetime maximum benefit of one testing.

(P.A. 11-88, S. 1.)

History: P.A. 11-88 effective January 1, 2012.

See Sec. 38a-518o for similar provisions re group policies.

Sec. 38a-493. (Formerly Sec. 38-174k). Mandatory coverage for home health care. Deductibles. Exception from deductible limits for medical savings accounts, Archer MSAs and health savings accounts. (a) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage providing reimbursement for home health care to residents in this state.

(b) For the purposes of this section, “hospital” means an institution which is primarily engaged in providing, by or under the supervision of physicians, to inpatients (1) diagnostic, surgical and therapeutic services for medical diagnosis, treatment and care of injured, disabled or sick persons, or (2) medical rehabilitation services for the rehabilitation of injured, disabled or sick persons, provided “hospital” shall not include a residential care home, nursing home, rest home or alcohol or drug treatment facility, as defined in section 19a-490. For the purposes of this section and section 38a-494, “home health care” means the continued care and treatment of a covered person who is under the care of a physician but only if (A) continued hospitalization would otherwise have been required if home health care was not provided, except in the case of a covered person diagnosed by a physician as terminally ill with a prognosis of six months or less to live, and (B) the plan covering the home health care is established and approved in writing by such physician within seven days following termination of a hospital confinement as a resident inpatient for the same or a related condition for which the covered person was hospitalized, except that in the case of a covered person diagnosed by a physician as terminally ill with a prognosis of six months or less to live, such plan may be so established and approved at any time irrespective of whether such covered person was so confined or, if such covered person was so confined, irrespective of such seven-day period, and (C) such home health care is commenced within seven days following discharge, except in the case of a covered person diagnosed by a physician as terminally ill with a prognosis of six months or less to live.

(c) Home health care shall be provided by a home health agency. The term “home health agency” means an agency or organization which meets each of the following requirements: (1) It is primarily engaged in and is federally certified as a home health agency and duly licensed, if such licensing is required, by the appropriate licensing authority, to provide nursing and other therapeutic services, (2) its policies are established by a professional group associated with such agency or organization, including at least one physician and at least one registered nurse, to govern the services provided, (3) it provides for full-time supervision of such services by a physician or by a registered nurse, (4) it maintains a complete medical record on each patient, and (5) it has an administrator.

(d) Home health care shall consist of, but shall not be limited to, the following: (1) Part-time or intermittent nursing care by a registered nurse or by a licensed practical nurse under the supervision of a registered nurse, if the services of a registered nurse are not available; (2) part-time or intermittent home health aide services, consisting primarily of patient care of a medical or therapeutic nature by other than a registered or licensed practical nurse; (3) physical, occupational or speech therapy; (4) medical supplies, drugs and medicines prescribed by a physician, advanced practice registered nurse or physician assistant and laboratory services to the extent such charges would have been covered under the policy or contract if the covered person had remained or had been confined in the hospital; (5) medical social services, as hereinafter defined, provided to or for the benefit of a covered person diagnosed by a physician as terminally ill with a prognosis of six months or less to live. Medical social services are defined to mean services rendered, under the direction of a physician by a qualified social worker holding a master’s degree from an accredited school of social work, including but not limited to (A) assessment of the social, psychological and family problems related to or arising out of such covered person’s illness and treatment; (B) appropriate action and utilization of community resources to assist in resolving such problems; (C) participation in the development of the overall plan of treatment for such covered person.

(e) The policy may contain a limitation on the number of home health care visits for which benefits are payable, but the number of such visits shall not be less than eighty in any calendar year or in any continuous period of twelve months for each person covered under a policy or contract, except in the case of a covered person diagnosed by a physician as terminally ill with a prognosis of six months or less to live, the yearly benefit for medical social services shall not exceed two hundred dollars. Each visit by a representative of a home health agency shall be considered as one home health care visit; four hours of home health aide service shall be considered as one home health care visit.

(f) Home health care benefits may be subject to an annual deductible of not more than fifty dollars for each person covered under a policy and may be subject to a coinsurance provision which provides for coverage of not less than seventy-five per cent of the reasonable charges for such services. Such policy may also contain reasonable limitations and exclusions applicable to home health care coverage. A “high deductible health plan”, as defined in Section 220(c)(2) or Section 223(c)(2) of the Internal Revenue Code of 1986, or any subsequent corresponding internal revenue code of the United States, as from time to time amended, used to establish a “medical savings account” or “Archer MSA” pursuant to Section 220 of said Internal Revenue Code or a “health savings account” pursuant to Section 223 of said Internal Revenue Code shall not be subject to the deductible limits set forth in this subsection.

(g) No policy, except any major medical expense policy as described in subsection (j), shall be required to provide home health care coverage to persons eligible for Medicare.

(h) No insurer, hospital service corporation or health care center shall be required to provide benefits beyond the maximum amount limits contained in its policy.

(i) If a person is eligible for home health care coverage under more than one policy, the home health care benefits shall only be provided by that policy which would have provided the greatest benefits for hospitalization if the person had remained or had been hospitalized.

(j) Each individual major medical expense policy delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage in accordance with the provisions of this section for home health care to residents in this state whose benefits are no longer provided under Medicare or any applicable individual health insurance policy.

(P.A. 75-623, S. 1; P.A. 78-76, S. 1–3, 5; P.A. 84-375, S. 1, 3; P.A. 89-284; P.A. 90-243, S. 83; P.A. 96-19, S. 6; P.A. 97-112, S. 2; P.A. 03-78, S. 1; P.A. 04-174, S. 6; P.A. 11-19, S. 41, 43.)

History: P.A. 78-76 specified applicability or inapplicability of provisions with respect to persons diagnosed as terminally ill with six months or less to live in Subsecs. (b), (d) and (e) and added “or had been” in Subsec. (i) preceding “hospitalized”; P.A. 84-375 amended Subsec. (g) to exclude major medical expense policies, as described in Subsec. (j), from the exemption in the subsection and added Subsec. (j), requiring that each major medical policy delivered, issued or renewed on or after October 1, 1984, provide coverage for home health care to residents who have exhausted their other policy or contract benefits; P.A. 89-284 amended Subsec. (b) to include a definition of “hospital” and amended Subsec. (j) to clarify that home health care shall be provided in accordance with this section under the major medical policies of insureds whose benefits are no longer provided under Medicare; P.A. 90-243 substituted references to “health insurance policies” for references to hospital and medical expense policies or contracts, added reference to health care centers and specified applicability solely to individual policies (Revisor’s note: The reference to “or contract” at the end of Subsec. (h) was deleted editorially by the Revisors for conformity with the changes made by P.A. 90-243); Sec. 38-174k transferred to Sec. 38a-493 in 1991; P.A. 96-19 expanded reference in Subsec. (d) to prescriptions by physicians to include advanced practice registered nurses and physician assistants; P.A. 97-112 replaced “home for the aged” with “residential care home”; P.A. 03-78 amended Subsec. (f) to provide that a high deductible health plan shall not be subject to the deductible limits set forth in said Subsec., effective July 1, 2003; P.A. 04-174 amended Subsec. (f) to add references to “Archer MSA”, “health savings account” and Section 223 of the Internal Revenue Code re “high deductible health plans”, effective June 1, 2004; P.A. 11-19 inserted “amended or continued” and made technical changes in Subsecs. (a) and (j), effective January 1, 2012.

See Sec. 38a-520 for similar provisions re group policies.

Sec. 38a-494. (Formerly Sec. 38-174l). Home health care by recognized nonmedical systems. Notwithstanding the provisions of section 38a-493, no insurer, health care center or issuer of any service plan contract for hospital or medical expense delivered, issued for delivery or renewed in this state shall be prohibited from providing, at its own discretion, coverage for home health care to persons employing a recognized nonmedical system of health care and treatment.

(P.A. 75-623, S. 2; P.A. 90-243, S. 84.)

History: P.A. 90-243 added reference to health care centers; Sec. 38-174l transferred to Sec. 38a-494 in 1991.

Sec. 38a-495. (Formerly Sec. 38-174m). Medicare supplement policies. Coverage of home health aid services and mammography. Prescription drug riders. (a) As used in this section, “Medicare” means the Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965, as amended (Title I, Part I of P.L. 89-97); “Medicare supplement policy” means any individual health insurance policy delivered or issued for delivery to any resident of the state who is eligible for Medicare, except any long-term care policy as defined in section 38a-501.

(b) No insurance company, fraternal benefit society, hospital service corporation, medical service corporation or health care center may deliver or issue for delivery any Medicare supplement policy which has an anticipated loss ratio of less than sixty-five per cent for any individual Medicare supplement policy defined in Section 1882(g) of Title XVIII of the Social Security Act, 42 USC 1395ss(g), as amended. No such company, society or corporation may deliver or issue for delivery any Medicare supplement policy without providing, at the time of solicitation or application for the purchase or sale of such coverage, full and fair disclosure of any coverage supplementing or duplicating Medicare benefits.

(c) Each Medicare supplement policy shall provide coverage for home health aide services for each individual covered under the policy when such services are not paid for by Medicare, provided (1) such services are provided by a certified home health aide employed by a home health care agency licensed pursuant to sections 19a-490 to 19a-503, inclusive, and (2) the individual’s physician has certified, in writing, that such services are medically necessary. The policy shall not be required to provide benefits in excess of five hundred dollars per year for such services. No deductible or coinsurance provisions may be applicable to such benefits. If two or more Medicare supplement policies are issued to the same individual by the same insurer, such coverage for home health aide services shall be included in only one such policy. Notwithstanding the provisions of subsection (g) of this section, the provisions of this subsection shall apply with respect to any Medicare supplement policy delivered, issued for delivery, continued or renewed in this state on or after October 1, 1986.

(d) Whenever a Medicare supplement policy provides coverage for the cost of prescription drugs prescribed after the hospitalization of the insured, outpatient surgical procedures performed on the insured in any licensed hospital shall constitute “hospitalization” for purposes of such prescription drug coverage in such policy.

(e) Notwithstanding the provisions of subsection (g) of this section, each Medicare supplement policy delivered, issued for delivery, continued or renewed in this state on or after October 1, 1988, shall provide benefits, to any woman covered under the policy, for mammographic examinations every year, or more frequently if recommended by the woman’s physician, when such examinations are not paid for by Medicare.

(f) The Insurance Commissioner shall adopt such regulations as he deems necessary in accordance with chapter 54 to carry out the purposes of this section.

(g) The provisions of this section shall apply with respect to any Medicare supplement policy delivered, issued for delivery, continued or renewed in this state on or after October 1, 1987, and prior to the effective date of any regulations adopted pursuant to section 38a-495a.

(P.A. 79-289, S. 1, 2; P.A. 81-97; P.A. 86-49, S. 1, 3; 86-152; P.A. 87-181; 87-502; P.A. 88-124, S. 2; P.A. 90-243, S. 85; P.A. 92-111, S. 2, 4.)

History: P.A. 81-97 amended Subsec. (b), providing that a loss ratio of 75% be required for a group medicare supplement policy defined in the federal act; P.A. 86-49 excluded long-term care policies from the definition of “Medicare supplement policy”; P.A. 86-152 inserted new Subsec. (c) requiring that Medicare supplement policies provide coverage for home health aide services, relettering prior Subsecs. as necessary; P.A. 87-181 amended Subsec. (c) to make its provisions applicable to any Medicare supplement policy delivered, issued for delivery, continued or renewed on or after October 1, 1986; P.A. 87-502 inserted new Subsec. (d) defining what constitutes “hospitalization” for purposes of prescription drug coverage, relettering prior Subsecs. as necessary; P.A. 88-124 inserted new Subsec. (e) requiring that Medicare supplement policies provide coverage for mammography, relettering prior Subsecs. as necessary; P.A. 90-243 added references to health care centers, deleted provisions concerning group policies and substituted reference to health insurance policies for reference to accident and sickness policies; Sec. 38-174m transferred to Sec. 38a-495 in 1991; P.A. 92-111 amended Subsec. (g) to make the provisions of this section applicable to Medicare supplement policy regulations adopted pursuant to Sec. 38a-495a.

See Secs. 38a-199 to 38a-209, inclusive, re hospital service corporations.

See Secs. 38a-214 to 38a-225, inclusive, re medical service corporations.

See Sec. 38a-495a re Medicare supplement policies and certificates.

See Sec. 38a-522 re group Medicare supplement policies and certificates.

See Secs. 38a-595 to 38a-626, inclusive, 38a-631 to 38a-640, inclusive, and 38a-800 re fraternal benefit societies.

Sec. 38a-495a. Medicare supplement policies and certificates. Minimum required policy benefits and standards. Regulations. (a) As used in this section:

(1) “Applicant” means (A) in the case of an individual Medicare supplement policy, a person who seeks to contract for insurance benefits or (B) in the case of a group Medicare supplement policy, a proposed certificate holder.

(2) “Certificate” means any certificate delivered or issued for delivery in this state under a group Medicare supplement policy.

(3) “Certificate form” means a form on which the certificate is delivered or issued for delivery by an insurer.

(4) “Commissioner” means the Insurance Commissioner.

(5) “Issuer” means any insurance company, fraternal benefit society, hospital or medical service corporation, health care center or any other entity which delivers or issues for delivery, in this state, any Medicare supplement policies or certificates.

(6) “Medicare” means the Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965, as then constituted or later amended.

(7) “Medicare supplement policy” means (A) a group or individual policy of accident and sickness insurance or (B) a subscriber contract of hospital and medical service corporations or health care centers, other than a policy issued pursuant to a contract under Section 1876 of the federal Social Security Act (42 USC Section 1395 et seq.), or (C) an issued policy under a demonstration project specified in 42 USC Section 1395ss(g)(1), which is advertised, marketed or designed primarily as a supplement to reimbursements under Medicare for the hospital, medical or surgical expenses of persons eligible for Medicare.

(8) “Policy form” means the form on which the policy is delivered or issued for delivery by the issuer.

(b) Except as otherwise specifically excluded, this section shall apply to all Medicare supplement policies and certificates delivered or issued for delivery in this state on or after July 30, 1992.

(c) This section shall not apply to a policy of one or more employers or labor organizations, or of the trustees of a fund established by one or more employers or labor organizations, or combination thereof, for employees or former employees or a combination thereof, or for members or former members, or a combination thereof, of the labor organizations.

(d) Except as otherwise specifically provided in subdivision (4) of subsection (l) of this section, the provisions of this section shall not apply to insurance policies or health care benefit plans, including group conversion policies, provided to Medicare eligible persons which policies are not marketed or held to be Medicare supplement policies or benefit plans.

(e) No Medicare supplement policy or certificate in force in this state shall contain benefits that duplicate benefits provided by Medicare.

(f) Notwithstanding any other provision of law, a Medicare supplement policy or certificate shall not exclude or limit benefits for losses incurred more than six months from the effective date of coverage because it involved a preexisting condition. The policy or certificate shall not define a preexisting condition more restrictively than a condition for which medical advice was given or treatment was recommended by or received from a physician within six months before the effective date of coverage.

(g) The commissioner shall adopt regulations in accordance with chapter 54 to establish specific standards for policy provisions of Medicare supplement policies and certificates. No requirements of this title relating to minimum required policy benefits, other than the minimum standards contained in this section, shall apply to Medicare supplement policies and certificates. The standards may include but need not be limited to the following: (1) Terms of renewability; (2) initial and subsequent conditions of eligibility; (3) nonduplication of coverage; (4) probationary periods; (5) benefit limitations, exceptions and reductions; (6) elimination periods; (7) requirements for replacement; (8) recurrent conditions; and (9) definitions of terms.

(h) The commissioner shall adopt regulations, in accordance with chapter 54, to establish minimum standards for benefits, claim payments, marketing practices, compensation arrangements and reporting practices for Medicare supplement policies and certificates.

(i) The commissioner may adopt such regulations, in accordance with chapter 54, as are necessary to conform Medicare supplement policies and certificates to the requirements of federal law. Such regulations may include but need not be limited to: (1) Requiring refunds or credits if the policies or certificates do not meet loss ratio requirements; (2) establishing a uniform methodology for calculating and reporting loss ratios; (3) assuring public access to policies, premiums and loss ratio information of issuers of Medicare supplement insurance; (4) establishing a process for approving or disapproving policy forms, certificate forms and proposed premium increases; (5) establishing a policy for holding public hearings prior to approval of premium increases; and (6) establishing standards for Medicare select policies and certificates.

(j) The commissioner may adopt regulations, in accordance with chapter 54, that specify prohibited policy provisions not otherwise specifically authorized which in the opinion of the commissioner, are unjust, unfair or unfairly discriminatory to any person insured or proposed to be insured under a Medicare supplement policy or certificate.

(k) Medicare supplement policies shall return to policyholders benefits which are reasonable in relation to the premiums charged. The commissioner shall adopt regulations, in accordance with chapter 54, to establish minimum standards for loss ratios of Medicare supplement policies on the basis of incurred claim experience, or incurred health care expenses where coverage is provided by a health care center on a service rather than a reimbursement basis, and earned premiums in accordance with accepted actuarial principles and practices.

(l) (1) In order to provide for full and fair disclosure in the sale of Medicare supplement policies, no Medicare supplement policy or certificate shall be delivered in this state unless an outline of coverage is delivered to the applicant at the time application is made.

(2) The commissioner shall adopt regulations in accordance with the provisions of chapter 54 to prescribe the format and content of the outline of coverage required by this subsection. For purposes of this subsection, “format” means style, arrangements and overall appearance, including such items as the size, color and prominence of type and arrangement of text and captions. The outline of coverage shall include: (A) A description of the principal benefits and coverage provided in the policy; (B) a statement of the renewal provisions, including any reservation by the issuer of a right to change premiums; and (C) a statement that the outline of coverage is a summary of the policy issued or applied for and that the policy should be consulted to determine the governing contractual provisions.

(3) The commissioner may prescribe by regulation a standard form and the contents of an informational brochure for persons eligible for Medicare, which is intended to improve the buyer’s ability to select the most appropriate coverage and improve the buyer’s understanding of Medicare. Except for direct response insurance policies, the commissioner may require by regulation that the informational brochure be provided to any prospective insured eligible for Medicare concurrently with the delivery of the outline of coverage. With respect to direct response insurance policies, the commissioner may require by regulation that the prescribed brochure be provided upon request to any prospective insured eligible for Medicare, but in no event later than the time of policy delivery.

(4) The commissioner may adopt regulations, in accordance with chapter 54, for captions or notice requirements, determined to be in the public interest and designed to inform the prospective insured that particular insurance coverages are not Medicare supplement coverages, for all accident and sickness insurance policies sold to persons eligible for Medicare, other than: (A) Medicare supplement policies; or (B) disability income policies.

(5) The commissioner may adopt regulations, in accordance with chapter 54, to govern the full and fair disclosure of the information in connection with the replacement of accident and sickness policies, subscriber contracts or certificates by persons eligible for Medicare.

(m) Medicare supplement policies and certificates shall have a notice prominently printed on the first page of the policy or certificate or attached thereto stating in substance that the applicant shall have the right to return the policy or certificate within thirty days of its delivery and to have the premium refunded if, after examination of the policy or certificate, the applicant is not satisfied for any reason. Any refund made pursuant to this section shall be paid directly to the applicant by the issuer in a timely manner.

(n) Every issuer of Medicare supplement insurance policies or certificates in this state shall provide a copy of any Medicare supplement advertisement intended for use in this state, whether through written, radio or television medium to the commissioner for his review or approval to the extent required by regulations, adopted pursuant to section 38a-819.

(o) In addition to any other applicable penalties for violations of this title, the commissioner may require issuers violating any provision of this section or any regulations promulgated pursuant to this section to cease marketing any Medicare supplement policies or certificates in this state which is related directly or indirectly to a violation or take such actions as are necessary to comply with the provisions of this section, or both.

(P.A. 92-111, S. 1, 4; P.A. 93-390, S. 6, 8; P.A. 97-57, S. 1–4; P.A. 10-5, S. 22.)

History: P.A. 93-390 amended Subsec. (l) by deleting provision requiring outline of coverage to include automatic renewal premium increases in policyholders’ premiums based on age, effective January 1, 1994; P.A. 97-57 amended Subsec. (a)(7) to delete reference to Section 1833 of the federal Social Security Act and replaced “demonstration project authorized pursuant to amendments to the federal Social Security Act” with “demonstration project specified in 42 USC Section 1395ss(g)(1), amended Subsec. (d) to make subsection subject to Subsec. (l)(4) of section and amended said Subsec. (l)(4) to delete reference to policies issued by reason of age, and to delete Subparas. (C) and (D), effective May 14, 1997; P.A. 10-5 made a technical change in Subsec. (f), effective May 5, 2010.

See Sec. 38a-495 re Medicare supplement policies and certificates.

See Sec. 38a-522 re group Medicare supplement policies and certificates.

Sec. 38a-495b. Medicare supplement policies and certificates. Definitions. (a) As used in sections 38a-473, 38a-474 and 38a-481, subsection (l) of section 38a-495a, sections 38a-495c and 38a-513 and this section, “Medicare” means the Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965, as amended (Title I, Part I of P.L. 89-97). For policies or certificates delivered or issued for delivery to any resident of this state who is eligible for Medicare, prior to July 30, 1992, “Medicare supplement policy” means any individual or group health insurance policy or certificate delivered or issued for delivery to any resident of the state who is eligible for Medicare, except any long-term care policy as defined in sections 38a-501 and 38a-528. For policies or certificates delivered or issued for delivery to any resident on or after July 30, 1992, “Medicare supplement policy” means (A) a group or individual policy of accident and sickness insurance or (B) a subscriber contract of hospital and medical service corporations or health care centers, other than a policy issued pursuant to a contract under Section 1876 or Section 1833 of the federal Social Security Act (42 USC Section 1395 et seq.), or (C) an issued policy under a demonstration project authorized pursuant to amendments to the federal Social Security Act, which is advertised, marketed or designed primarily as a supplement to reimbursements under Medicare for the hospital, medical or surgical expenses of persons eligible for Medicare.

(b) In accordance with the regulations adopted pursuant to section 38a-495a, there shall be standardized Medicare supplement insurance policies or certificates as designated by the Centers for Medicare and Medicaid Services.

(P.A. 93-390, S. 1, 8; P.A. 05-20, S. 4; P.A. 11-19, S. 30.)

History: P.A. 93-390 effective January 1, 1994; P.A. 05-20 amended Subsec. (b) to substitute “July 1, 2005,” for “June 30, 1992,” and delete “ten” and substitute “A” to “L” for “A” to “J” re standardized policies or certificates, effective July 1, 2005; P.A. 11-19 amended Subsec. (b) to delete provision re Medicare supplement plans “A” to “L”, insert “Centers for Medicare and Medicaid Services” and make technical changes.

Sec. 38a-495c. Medicare supplement premium rates charged on a community rate basis. Age, gender, previous claim or medical history rating prohibited. Preexisting conditions. Coverage for the disabled. Regulations. (a) Each insurance company, fraternal benefit society, hospital service corporation, medical service corporation, health care center or other entity in this state that delivers, issues for delivery, continues or renews any Medicare supplement insurance policies or certificates shall base the premium rates charged on a community rate. Such rate shall not be based on age, gender, previous claims history or the medical condition of the person covered by such policy or certificate. Except as provided in subsection (c) of this section, coverage shall not be denied on the basis of age, gender, previous claim history or the medical condition of the person covered by such policy or certificate.

(b) Nothing in this section shall prohibit an insurance company, fraternal benefit society, hospital service corporation, medical service corporation, health care center or other entity in this state issuing Medicare supplement insurance policies or certificates from using its usual and customary underwriting procedures, provided no such company, society, corporation, center or other entity shall issue a Medicare supplement policy or certificate based on the age, gender, previous claims history or the medical condition of the applicant.

(c) Nothing in this section shall prohibit an insurance company, fraternal benefit society, hospital service corporation, medical service corporation, health care center or other entity in this state when granting coverage under a Medicare supplement policy or certificate from excluding benefits for losses incurred within six months from the effective date of coverage based on a preexisting condition, in accordance with section 38a-495a and the regulations adopted pursuant to section 38a-495a.

(d) Each insurance company, fraternal benefit society, hospital service corporation, medical service corporation, health care center or other entity in the state issuing Medicare supplement policies or certificates for plan “A”, “B” or “C”, or any combination thereof, to persons eligible for Medicare by reason of age, shall offer for sale the same such policies or certificates to persons eligible for Medicare by reason of disability.

(e) Each insurance company, fraternal benefit society, hospital service corporation, medical service corporation, health care center or other entity in the state issuing Medicare supplement policies or certificates shall make all necessary arrangements with the Medicare Part B carrier and all Medicare Part A intermediaries to allow for the forwarding, to the issuing entity, of all Medicare claims containing the name of the entity issuing a Medicare supplement policy or certificate and the identification number of an insured. The entity issuing the Medicare supplement policy or certificate shall process all benefits available to an insured from a Medicare claim so forwarded, without requiring any additional action on the part of the insured.

(f) The Insurance Commissioner may adopt regulations, in accordance with chapter 54, to implement this section.

(P.A. 93-390, S. 2, 8; Oct. Sp. Sess. P.A. 93-1, S. 1, 2; P.A. 98-32; P.A. 05-20, S. 5; P.A. 11-19, S. 31; P.A. 12-145, S. 14.)

History: P.A. 93-390 effective January 1, 1994; Oct. Sp. Sess. P.A. 93-1 inserted new Subsec. (c) re exclusion of benefits for losses incurred within six months from the effective date of coverage based on a preexisting condition and relettered the remaining Subsecs. accordingly, effective January 1, 1994 (Revisor’s note: In Subsecs. (d) and (e) the references to “other entities in the state” were changed editorially by the Revisors to “other entity in the state” for consistency with the language in Subsecs. (a), (b) and (c)); P.A. 98-32 amended Subsec. (d) to require those who issue Medicare supplements for plans “A”, “B” or “C”, or any combination thereof, on the basis of age to offer the same policy to persons eligible for Medicare by reason of disability, and deleted requirement that companies which issue Medicare supplements on basis of age must offer at least one such policy on basis of disability; P.A. 05-20 made technical changes throughout, amended Subsecs. (a) and (b) to reference “determinations to grant coverage” and plans “H” to “J”, inclusive, “issued prior to January 1, 2006,” re use of claims history and medical condition, and amended Subsec. (g) re regulations, effective July 1, 2005; P.A. 11-19 amended Subsecs. (a) and (b) to delete provisions re Medicare supplement plans “H” to “J”; P.A. 12-145 amended Subsec. (a) to delete “on or after January 1, 1994” and make a technical change, deleted former Subsec. (f) re application of section to policies or certificates issued on and after January 1, 1994, and redesignated existing Subsec. (g) as Subsec. (f), effective June 15, 2012.

Sec. 38a-495d. Refund of prepaid premium for Medicare supplement policies. Each insurance company, fraternal benefit society, hospital service corporation, medical service corporation, health care center or other entity which delivers or issues for delivery, continues or renews in this state any Medicare supplement policy or certificate, as defined in sections 38a-495, 38a-495a and 38a-522, shall refund any prepaid premium made by a policyholder or certificate holder for coverage under such policy or certificate who subsequently elects to cancel his or her policy prior to the expiration of the coverage period.

(P.A. 07-48, S. 1.)

Sec. 38a-496. (Formerly Sec. 38-174q). Coverage for occupational therapy. (a) For the purposes of this section:

(1) “Occupational therapy” means services provided by a licensed occupational therapist in accordance with a plan of care established and approved in writing by a physician licensed in accordance with the provisions of chapter 370, who has certified that the prescribed care and treatment are not available from sources other than a licensed occupational therapist and which are provided in private practice or in a licensed health care facility. Such plan shall be reviewed and certified at least every two months by such physician.

(2) “Health care facility” means an institution which provides occupational therapy, including, but not limited to, an outpatient clinic, a rehabilitative agency and a skilled or intermediate nursing facility.

(3) “Rehabilitative agency” means an agency which provides an integrated multitreatment program designed to upgrade the function of handicapped disabled individuals by bringing together, as a team, specialized personnel from various allied health fields.

(4) “Partial hospitalization” means a formal program of care provided in a hospital or facility for periods of less than twenty-four hours a day.

(b) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state that provides coverage for expenses incurred for physical therapy shall provide coverage for occupational therapy provided in private practice or in a health care facility or in a partial hospitalization program on an exchange basis.

(P.A. 82-148; P.A. 90-243, S. 86; P.A. 11-19, S. 45.)

History: P.A. 90-243 substituted reference to health insurance policies for reference to hospital and medical expense policies or contracts in Subsec. (b) and specified applicability solely to individual policies; Sec. 38-174q transferred to Sec. 38a-496 in 1991; P.A. 11-19 inserted “amended or continued” and made technical changes in Subsec. (b), effective January 1, 2012.

See Sec. 38a-524 for similar provisions re group policies.

Sec. 38a-497. (Formerly Sec. 38-174r). Termination of coverage of children in individual policies. Coverage for stepchildren. Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state shall provide that coverage of a child shall terminate no earlier than the policy anniversary date on or after whichever of the following occurs first, the date on which the child: Becomes covered under a group health plan through the dependent’s own employment; or attains the age of twenty-six. Each such policy shall cover a stepchild on the same basis as a biological child.

(P.A. 82-143; P.A. 90-243, S. 87; P.A. 07-185, S. 16; June Sp. Sess. P.A. 07-2, S. 64, 69; P.A. 08-147, S. 8; P.A. 09-124, S. 1; P.A. 11-58, S. 37.)

History: P.A. 90-243 substituted reference to health insurance policies for reference to hospital or medical expense policies and contracts and specified applicability solely to individual policies; Sec. 38-174r transferred to Sec. 38a-497 in 1991; P.A. 07-185 prohibited termination of coverage of a child prior to the policy anniversary date on or after the earliest of the date on which the child marries, ceases to be a resident of the state or attains the age of 26, for any policy delivered, issued for delivery, amended or renewed on or after October 1, 2007, effective July 1, 2007; June Sp. Sess. P.A. 07-2 changed effective date of P.A. 07-185, S. 16 to January 1, 2009, effective June 26, 2007, and applied provisions to policies delivered, issued for delivery, amended or renewed in this state on or after January 1, 2009, and made provisions allowing children to maintain coverage until age 26 contingent upon children remaining state residents, except for full-time attendance at an out-of-state accredited institution of higher education or residency with a custodial parent pursuant to a child custody determination, effective January 1, 2009; P.A. 08-147 revised conditions upon which coverage of a child terminates by adding provision re coverage under a group health plan through a dependent child’s own employment, deleting custodial parent provision, and specifying that dependent children to age 19 are exempt from state residency requirement, effective January 1, 2009; P.A. 09-124 inserted “or continued”, made a technical change and added requirement that a stepchild be covered on the same basis as a biological child, effective June 18, 2009; P.A. 11-58 deleted requirements for termination of dependent coverage re marriage and state residency of a child, and made a technical change, effective July 2, 2011.

See Sec. 38a-508 for provisions re adopted children.

See Sec. 38a-512b for similar provisions re group policies.

Sec. 38a-497a. Group coverage and benefits of a noncustodial parent. National Medical Support Notice. Notification of new employer by IV-D agency. Notification to parent. Enrollment of child. (a) As used in this section (1) “insurer” shall have the same meaning as “insurer”, as defined in 42 USC S 1396g-l(b), as including a group health plan, as defined in 29 USC S 1167(1), an employee welfare benefit plan providing medical care to participants or beneficiaries directly or through insurance reimbursement, or otherwise, a health maintenance organization and an entity offering a service benefit plan, and (2) “NMSN” means a National Medical Support Notice issued in a Title IV-D support case pursuant to section 46b-88.

(b) If a child has health insurance coverage through an insurer of a noncustodial parent, such insurer shall: (1) Provide such information to the custodial parent as may be necessary for the child to obtain benefits through such coverage; (2) permit the custodial parent, or the health care provider, with the custodial parent’s approval, to submit claims for covered services without the approval of the noncustodial parent; (3) make payments on claims submitted in accordance with this section directly to the custodial parent, the health care provider or the Department of Social Services; and (4) comply with the terms of any applicable NMSN.

(c) An insurer shall not deny enrollment of a child under the group health plan of the child’s parent if: (1) The child was born out of wedlock, provided the father of the child has acknowledged paternity pursuant to section 46b-172 or has been adjudicated the father pursuant to section 46b-171; (2) the child is not claimed as a dependent on the federal income tax return of the parent; (3) the child does not reside with the parent or in the insurer’s service area; or (4) if the child is receiving, or is eligible for benefits under a state medical assistance plan required by the Social Security Act.

(d) If a parent is required by a court or family support magistrate to provide health coverage for a child, and the parent is eligible for family health coverage, the insurer shall permit the parent to enroll, or shall enroll pursuant to any applicable NMSN, under the family coverage, a child who is otherwise eligible for such coverage without regard to any open enrollment restrictions. If enrollment of a child is dependent on the enrollment of a participant who is not enrolled, both the child and the participant shall be enrolled. If the parent is enrolled for coverage but fails to make application to obtain coverage for a child, the insurer shall enroll such child under family coverage upon application of such child’s other parent, the state agency administering the Medicaid program or the state agency administering Title IV-D of the Social Security Act, or upon receipt of a NMSN, as provided in section 46b-88. The insurer shall not disenroll or eliminate coverage of such child unless the insurer is provided with satisfactory written evidence that the court or administrative order is no longer in effect or the child is enrolled or shall be enrolled in comparable health coverage through another insurer which shall take effect no later than the effective date of such disenrollment, or the employer eliminates family health coverage for all its employees.

(e) If a parent is required by a court or an administrative order to provide health coverage for a child and the parent is eligible for family health coverage through an employer doing business in the state, such employer shall permit such parent to enroll such child under such coverage without regard to any open enrollment restrictions. If a parent is enrolled but fails to make application to obtain coverage of a child, the employer shall enroll such child under health care coverage upon application by the child’s other parent or by the Commissioner of Social Services, or his designee, when such child is eligible under the Medicaid program or is receiving child support enforcement services pursuant to Title IV-D of the Social Security Act. A NMSN shall constitute an application for health care coverage by the issuing agency. If a noncustodial parent in a IV-D case provides such coverage and changes employment, and the new employer provides health care coverage, the IV-D agency or an agency under cooperative agreement therewith shall transfer notice of the provision for health care coverage to such new employer, as provided in section 46b-88. A NMSN shall operate to enroll the child in the parent’s health care plan if that portion of the parent’s income which is subject to withholding pursuant to subsection (e) of section 52-362, is sufficient to cover both the current support order and health care coverage. At the time notice is transferred to the employer, the IV-D agency, or an agency under cooperative agreement therewith, shall also cause a copy of the notice of such transfer of health care coverage to be delivered to each parent. A parent may contest such notice by filing a motion for modification with the family support magistrate. An employer, subject to the provisions of this section, shall not disenroll or eliminate coverage of any such child unless the employer is provided satisfactory written evidence that: (1) A court or an administrative order for health care coverage is no longer in effect; (2) the child is or shall be enrolled in comparable health care coverage which shall take effect not later than the effective date of such disenrollment or elimination; or (3) the employer has eliminated family health care coverage for all of its employees.

(May Sp. Sess. P.A. 94-5, S. 4, 30; P.A. 95-305, S. 1, 6; June 18 Sp. Sess. P.A. 97-7, S. 15, 38; P.A. 98-27, S. 16; May 9 Sp. Sess. P.A. 02-7, S. 41; P.A. 07-247, S. 5.)

History: May Sp. Sess. P.A. 94-5 effective July 1, 1994; P.A. 95-305 inserted new Subsec. (a) defining “insurer”, relettering existing provisions as Subsec. (b) and added Subsecs. (c), (d) and (e) which provide requirements for the enrollment of a child in a parent’s health plan, deleted former Subsec. (b) re adoption of regulations and made technical changes, effective July 1, 1995; June 18 Sp. Sess. P.A. 97-7 amended Subsec. (e) by adding provision re notification of new employer of noncustodial parent and notification of obligor and custodial parent re transfer of health insurance coverage and contest by noncustodial parent, effective July 1, 1997; P.A. 98-27 made a technical change in Subsec. (e); May 9 Sp. Sess. P.A. 02-7 amended Subsec. (a) by designating definition of “insurer” as Subdiv. (1), making a technical change therein and adding Subdiv. (2) defining “NMSN”, added Subsec. (b)(4) re compliance with NMSN, amended Subsec. (c) by changing “health plan” to “group health plan” and adding Subdiv. (4) re benefits under state medical assistance plan, amended Subsec. (d) by adding provisions re enrollment pursuant to and receipt of NMSN, enrollment dependent upon enrollment of participant and elimination of family health coverage by employer, and amended Subsec. (e) by adding provision re NMSN as application for health care coverage and reference to Sec. 46b-88; P.A. 07-247 amended Subsec. (e) by substituting “parent’s” income for “obligor’s” income and “each” parent for “the obligor and to the custodial” parent, by deleting reference to “noncustodial” parent, by substituting “A NMSN” for “The notice” and by adding “current” re support order.

See Sec. 46b-88 re National Medical Support Notice.

Sec. 38a-498. (Formerly Sec. 38-174t). Mandatory coverage for medically necessary ambulance services. Direct payment to ambulance provider. (a) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for medically necessary ambulance services for persons covered by the policy. The hospital policy shall be primary if a person is covered under more than one policy. The policy shall, as a minimum requirement, cover such services whenever any person covered by the contract is transported when medically necessary by ambulance to a hospital. Such benefits shall be subject to any policy provision which applies to other services covered by such policies. Notwithstanding any other provision of this section, such policies shall not be required to provide benefits in excess of the maximum allowable rate established by the Department of Public Health in accordance with section 19a-177.

(b) (1) Each such individual health insurance policy shall provide that any payment by such company, corporation or center for emergency ambulance services under coverage required by this section shall be paid directly to the ambulance provider rendering such service if such provider has complied with the provisions of this subsection and has not received payment for such service from any other source.

(2) Any ambulance provider submitting a bill for direct payment pursuant to this section shall stamp the following statement on the face of each bill: “NOTICE: This bill subject to mandatory assignment pursuant to Connecticut general statutes”.

(3) This subsection shall not apply to any transaction between an ambulance provider and an insurance company, hospital or medical service corporation, health care center or other entity if the parties have entered into a contract providing for direct payment.

(P.A. 83-325; P.A. 84-375, S. 2, 4; P.A. 90-243, S. 88; P.A. 94-239, S. 1; P.A. 02-124, S. 1; P.A. 12-145, S. 58.)

History: P.A. 84-375 amended Subsec. (a) to provide that on and after March 1, 1984, each hospital or medical expense insurance policy or hospital or medical service plan contract shall provide such coverage for ambulance services, that with more than one policy or contract, the hospital policy or contract shall be primary, that the benefits shall be subject to applicable policy or contract provisions, and $500 shall be the maximum mandatory benefit and added Subsec. (b), mandating direct payment to ambulance providers who meet certain requirements; P.A. 90-243 substituted reference to health insurance policies for reference to hospital and medical expense policies and contracts, deleted former Subsec. (b)(1) re group policies and designated former Subdivs. (2) and (3) as (1) and (2); Sec. 38-174t transferred to Sec. 38a-498 in 1991; P.A. 94-239 substituted “medically necessary” for “emergency” ambulance services and deleted the provision that the patient be admitted to the hospital; P.A. 02-124 amended Subsec. (a) to substitute “each” for “every”, rewrite provisions re policies renewed or amended in this state, substitute “October 1, 2002” for “March 1, 1984”, and substitute the maximum allowable rate established by the Department of Public Health for $500 re the maximum required coverage, inserted new Subsec. (b)(1) re direct payment for provider who complies with subsection, renumbered Subsecs. (b)(1) and (b)(2) as Subsecs. (b)(2) and (b)(3), respectively, and amended Subsec. (b)(3) to add “health care center or other entity”; P.A. 12-145 amended Subsec. (a) to add “or continued” re policy and delete “on or after October 1, 2002”, effective January 1, 2013.

See Sec. 38a-525 for similar provisions re group policies.

Sec. 38a-498a. Preauthorization prohibited for certain 9-1-1 emergency calls. No individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469, delivered, issued for delivery or renewed in this state, on or after October 1, 1996, shall direct or require an enrollee to obtain approval from the insurer or health care center prior to calling a 9-1-1 local prehospital emergency medical service system whenever such enrollee is confronted with a life or limb threatening emergency. For purposes of this section, a “life or limb threatening emergency” means any event which the enrollee believes threatens his life or limb in such a manner that a need for immediate medical care is created to prevent death or serious impairment of health.

(P.A. 96-67, S. 1.)

History: (Revisor’s note: In codifying public act 96-67 an incorrect reference to “of subsection (a)” appearing before the reference to “section 38a-469” was deleted editorially by the Revisors).

See Sec. 38a-525a for similar provisions re group policies.

Sec. 38a-498b. Mandatory coverage for mobile field hospital. Each individual health insurance policy providing coverage of the type specified in subdivisions (1) to (13), inclusive, of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide benefits for isolation care and emergency services provided by the state’s mobile field hospital. Such benefits shall be subject to any policy provisions that apply to other services covered by such policy. The rates paid by individual health insurance policies pursuant to this section shall be equal to the rates paid under the Medicaid program, as determined by the Department of Social Services.

(P.A. 05-280, S. 64; P.A. 07-252, S. 70; P.A. 12-145, S. 49.)

History: P.A. 05-280 effective July 1, 2005; P.A. 07-252 substituted “mobile field hospital” for “critical access hospital” and made a technical change, effective July 12, 2007; P.A. 12-145 deleted “on or after July 1, 2005” and made a technical change, effective June 15, 2012.

See Sec. 38a-525b for similar provisions re group policies.

Sec. 38a-498c. Denial of coverage prohibited for health care services rendered to persons with an elevated blood alcohol content. No individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state shall deny coverage for health care services rendered to treat any injury sustained by any person when such injury is alleged to have occurred or occurs under circumstances in which (1) such person has an elevated blood alcohol content, or (2) such person has sustained such injury while under the influence of intoxicating liquor or any drug or both. For the purposes of this section, “elevated blood alcohol content” means a ratio of alcohol in the blood of such person that is eight-hundredths of one per cent or more of alcohol, by weight.

(P.A. 06-39, S. 1; P.A. 12-145, S. 51.)

History: P.A. 12-145 deleted “on or after October 1, 2006”, effective June 15, 2012.

See Sec. 38a-525c for similar provisions re group policies.

Sec. 38a-499. (Formerly Sec. 38-174v). Mandatory coverage for services of physician assistants and certain nurses. (a) For the purposes of this section:

(1) “Certified nurse practitioner” means any registered nurse licensed under chapter 378 who has completed a formal educational nurse practitioner program and is certified by the American Nurses’ Association, the National Board of Pediatric Nurse Practitioners and Associates or the Nurses’ Association of the American College of Obstetricians and Gynecologists;

(2) “Certified psychiatric-mental health clinical nurse specialist” means any registered nurse licensed under chapter 378 who has completed a formal educational program as a psychiatric-mental health clinical nurse specialist and is certified by the American Nurses’ Association;

(3) “Certified nurse-midwife” means any individual certified as nurse-midwife pursuant to sections 20-86a to 20-86e, inclusive;

(4) “Physician assistant” means an individual licensed pursuant to section 20-12b.

(b) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for the services of physician assistants, certified nurse practitioners, certified psychiatric-mental health clinical nurse specialists and certified nurse-midwives if such services are within the individual’s area of professional competence as established by education and licensure or certification and are currently reimbursed when rendered by any other licensed health care provider. Subject to the provisions of chapter 378 and sections 20-86a to 20-86e, inclusive, no insurer, hospital service corporation, medical service corporation or health care center may require signature, referral or employment by any other health care provider as a condition of reimbursement, provided no insurer, hospital service corporation, medical service corporation or health care center may be required to pay for duplicative services actually rendered by both a physician assistant or a certified registered nurse and any other health care provider. The payment of such benefits shall be subject to any policy provisions which apply to other licensed health practitioners providing the same services. Nothing in this section may be construed as permitting (1) any registered nurse to perform or provide services beyond the scope of practice permitted in chapter 378 and sections 20-86a to 20-86e, inclusive, or (2) any physician assistant to perform or provide services beyond the scope of practice permitted in chapter 370.

(P.A. 84-231; P.A. 90-243, S. 89; P.A. 95-74, S. 7, 9; P.A. 11-19, S. 47.)

History: P.A. 90-243 substituted references to “health insurance policy” for references to hospital and medical expense policies and contracts, applied provisions to health care centers and specified applicability solely to individual policies; Sec. 38-174v transferred to Sec. 38a-499 in 1991; P.A. 95-74 added physician assistants to those whose services must be included in coverage and defined “physician assistant”, effective July 1, 1995; P.A. 11-19 inserted “amended or continued” and made technical changes in Subsec. (b), effective January 1, 2012.

See Sec. 38a-526 for similar provisions re group policies.

Sec. 38a-500. (Formerly Sec. 38-174w). Mandatory coverage for partners, sole proprietors and corporate officers for work-related injuries. Subrogation rights. (a) Notwithstanding any other provision of the general statutes, no individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state may exclude coverage for a bodily injury solely because it was caused by an accident arising out of and in the course of employment to a covered individual who is: (1) A sole proprietor or business partner who is not covered by the provisions of chapter 568 or who accepts the provisions of chapter 568 pursuant to subdivision (10) of section 31-275; or (2) an employee of a corporation and who is a corporate officer, regardless of any election by such individual to be excluded from coverage under chapter 568 pursuant to subparagraph (B)(v) of subdivision (9) of section 31-275. The payment of benefits pursuant to this section shall be subject to any policy or contract provisions that apply to a claim not resulting from bodily injury caused by an accident arising out of and in the course of employment.

(b) Whenever any such covered individual who receives benefits for any such injury under such policy or contract has a right of recovery or reimbursement against any person or organization, any carrier that has paid such benefits to or for the individual shall be subrogated to all such rights of recovery or reimbursement to the extent of its payment. Such carrier shall also have a lien on the proceeds of any award or approval of any compromise made by a workers’ compensation commissioner pursuant to the individual’s workers’ compensation claim, in accordance with the provisions of section 38a-470.

(P.A. 84-499, S. 1; P.A. 90-243, S. 90; P.A. 10-5, S. 23.)

History: P.A. 90-243 substituted reference to health insurance policies for hospital and medical expense policies and contracts, specified applicability to individual policies only and made technical grammatical change; Sec. 38-174w transferred to Sec. 38a-500 in 1991; (Revisor’s note: In 1997 the phrase “type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) section 38a-469 delivered,” was changed editorially by the Revisors to “type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469 delivered,” to correct a clerical error); P.A. 10-5 deleted provision re first anniversary date of policy or contract and made technical changes in Subsec. (a), effective January 1, 2011.

See Sec. 38a-527 for similar provisions re group policies.

Sec. 38a-501. (Formerly Sec. 38-174x). Long-term care policies. (a)(1) As used in this section, “long-term care policy” means any individual health insurance policy delivered or issued for delivery to any resident of this state on or after July 1, 1986, that is designed to provide, within the terms and conditions of the policy, benefits on an expense-incurred, indemnity or prepaid basis for necessary care or treatment of an injury, illness or loss of functional capacity provided by a certified or licensed health care provider in a setting other than an acute care hospital, for at least one year after an elimination period (A) not to exceed one hundred days of confinement, or (B) of over one hundred days but not to exceed two years of confinement, provided such period is covered by an irrevocable trust in an amount estimated to be sufficient to furnish coverage to the grantor of the trust for the duration of the elimination period. Such trust shall create an unconditional duty to pay the full amount held in trust exclusively to cover the costs of confinement during the elimination period, subject only to taxes and any trustee’s charges allowed by law. Payment shall be made directly to the provider. The duty of the trustee may be enforced by the state, the grantor or any person acting on behalf of the grantor. A long-term care policy shall provide benefits for confinement in a nursing home or confinement in the insured’s own home or both. Any additional benefits provided shall be related to long-term treatment of an injury, illness or loss of functional capacity. “Long-term care policy” shall not include any such policy that is offered primarily to provide basic Medicare supplement coverage, basic medical-surgical expense coverage, hospital confinement indemnity coverage, major medical expense coverage, disability income protection coverage, accident only coverage, specified accident coverage or limited benefit health coverage.

(2) (A) No insurance company, fraternal benefit society, hospital service corporation, medical service corporation or health care center delivering, issuing for delivery, renewing, continuing or amending any long-term care policy in this state may refuse to accept or make reimbursement pursuant to a claim for benefits submitted by or prepared with the assistance of a managed residential community, as defined in section 19a-693, in accordance with subdivision (7) of subsection (a) of section 19a-694 solely because such claim for benefits was submitted by or prepared with the assistance of a managed residential community.

(B) Each insurance company, fraternal benefit society, hospital service corporation, medical service corporation or health care center delivering, issuing for delivery, renewing, continuing or amending any long-term care policy in this state shall, upon receipt of a written authorization executed by the insured, (i) disclose information to a managed residential community for the purpose of determining such insured’s eligibility for an insurance benefit or payment, and (ii) provide a copy of the initial acceptance or declination of a claim for benefits to the managed residential community at the same time such acceptance or declination is made to the insured.

(b) No insurance company, fraternal benefit society, hospital service corporation, medical service corporation or health care center may deliver or issue for delivery any long-term care policy that has a loss ratio of less than sixty per cent for any individual long-term care policy. An issuer shall not use or change premium rates for a long-term care insurance policy unless the rates have been filed with and approved by the Insurance Commissioner. Any rate filings or rate revisions shall demonstrate that anticipated claims in relation to premiums when combined with actual experience to date can be expected to comply with the loss ratio requirement of this section. A rate filing shall include the factors and methodology used to estimate irrevocable trust values if the policy includes an option for the elimination period specified in subdivision (1) of subsection (a) of this section.

(c) No such company, society, corporation or center may deliver or issue for delivery any long-term care policy without providing, at the time of solicitation or application for purchase or sale of such coverage, full and fair disclosure of the benefits and limitations of the policy. If the offering for any long-term care policy includes an option for the elimination period specified in subdivision (1) of subsection (a) of this section, the application form for such policy and the face page of such policy shall contain a clear and conspicuous disclosure that the irrevocable trust may not be sufficient to cover all costs during the elimination period.

(d) No such company, society, corporation or center may deliver or issue for delivery any long-term care policy on or after July 1, 2008, without offering, at the time of solicitation or application for purchase or sale of such coverage, an option to purchase a policy that includes a nonforfeiture benefit. Such offer of a nonforfeiture benefit may be in the form of a rider attached to such policy. In the event the nonforfeiture benefit is declined, such company, society, corporation or center shall provide a contingent benefit upon lapse that shall be available for a specified period of time following a substantial increase in premium rates. Not later than July 1, 2008, the Insurance Commissioner shall adopt regulations, in accordance with chapter 54, to implement the provisions of this subsection. Such regulations shall specify the type of nonforfeiture benefit that may be offered, the standards for such benefit, the period of time during which a contingent benefit upon lapse will be available and the substantial increase in premium rates that trigger a contingent benefit upon lapse in accordance with the Long-Term Care Insurance Model Regulation adopted by the National Association of Insurance Commissioners.

(e) The Insurance Commissioner shall adopt regulations, in accordance with chapter 54, that address (1) the insured’s right to information prior to his replacing an accident and sickness policy with a long-term care policy, (2) the insured’s right to return a long-term care policy to the insurer, within a specified period of time after delivery, for cancellation, and (3) the insured’s right to accept by the insured’s signature, and prior to it becoming effective, any rider or endorsement added to a long-term care policy after the issuance date of such policy. The Insurance Commissioner shall adopt such additional regulations as the commissioner deems necessary in accordance with chapter 54 to carry out the purpose of this section.

(f) The Insurance Commissioner may, upon written request by any such company, society, corporation or center, issue an order to modify or suspend a specific provision of this section or any regulation adopted pursuant thereto with respect to a specific long-term care policy upon a written finding that: (1) The modification or suspension would be in the best interest of the insureds; (2) the purposes to be achieved could not be effectively or efficiently achieved without such modification or suspension; and (3) (A) the modification or suspension is necessary to the development of an innovative and reasonable approach for insuring long-term care, (B) the policy is to be issued to residents of a life care or continuing care retirement community or other residential community for the elderly and the modification or suspension is reasonably related to the special needs or nature of such community, or (C) the modification or suspension is necessary to permit long-term care policies to be sold as part of, or in conjunction with, another insurance product. Whenever the commissioner decides not to issue such an order, the commissioner shall provide written notice of such decision to the requesting party in a timely manner.

(g) Upon written request by any such company, society, corporation or center, the Insurance Commissioner may issue an order to extend the preexisting condition exclusion period, as established by regulations adopted pursuant to this section, for purposes of specific age group categories in a specific long-term care policy form whenever the commissioner makes a written finding that such an extension is in the best interest to the public. Whenever the commissioner decides not to issue such an order, the commissioner shall provide written notice of such decision to the requesting party in a timely manner.

(h) The provisions of section 38a-19 shall be applicable to any such requesting party aggrieved by any order or decision of the commissioner made pursuant to subsections (f) and (g) of this section.

(P.A. 86-49, S. 2, 3; P.A. 89-236, S. 1, 3; P.A. 90-82; 90-243, S. 91; P.A. 91-276, S. 1; P.A. 94-39, S. 5; P.A. 07-28, S. 1; 07-226, S. 1; P.A. 10-127, S. 2; P.A. 12-145, S. 15.)

History: P.A. 89-236 amended Subsec. (a) further defining “long-term care policy”, amended Subsec. (c) excluding policies issued to certain groups from disclosure requirement, amended Subsec. (d) detailing regulations to be adopted, added Subsec. (e) providing modification or suspension of requirements under certain conditions, added Subsec. (f) providing extension of preexisting condition exclusion period under certain conditions and added Subsec. (g) re appeal of commissioner’s rulings; P.A. 90-82 allowed an insured the choice of a long-term care policy which provides benefits for confinement in the insured’s own home or a policy which allows coverage for both nursing home and own home care where previously coverage was limited to nursing home care; P.A. 90-243 substituted reference to health insurance policies for reference to accident and sickness policies and deleted provisions concerning group coverage; Sec. 38-174x transferred to Sec. 38a-501 in 1991; P.A. 91-276 substituted 60% for 55% in Subsec. (b) re loss ratio for any individual long-term care policy; P.A. 94-39 amended Subsec. (b) by adding provision to require that issuer not use or change premium rates for a long-term policy without the filing and approval of the insurance commissioner and that such filing or revision comply with the loss ratio requirement for any individual long-term care policy; P.A. 07-28 inserted new Subsec. (d) requiring an offer of a nonforfeiture benefit in policies delivered or issued for delivery on or after July 1, 2008, provision of a contingent benefit upon lapse if the nonforfeiture benefit is declined and adoption of regulations to implement provisions of Subsec., and redesignated existing Subsecs. (d) to (g) as Subsec. (e) to (h), effective July 1, 2007; P.A. 07-226 amended Subsec. (a) to require an elimination period that is up to 100 days of confinement, or over 100 days but not exceeding two years of confinement if such period is covered by an irrevocable trust in an amount sufficient to cover grantor’s confinement costs during such period, to require trust to create an unconditional duty to pay only confinement costs during such period, subject to taxes and trustee’s fees, and to require trust to pay the health care provider directly, amended Subsec. (b) to require rate filing to include factors and methodology used to estimate trust values, and amended Subsec. (c) to require clear and conspicuous disclosure on application form and face page of policy that trust may be insufficient to cover all costs during the elimination period; P.A. 10-127 amended Subsec. (a) by designating existing provisions as Subdiv. (1) and making technical changes therein, and by adding Subdiv. (2) re claims for benefits submitted or prepared by and disclosure of information to managed residential communities, effective July 1, 2010; P.A. 12-145 made technical changes, effective June 15, 2012.

Sec. 38a-502. (Formerly Sec. 38-174ff). Mandatory coverage for services provided by the Veterans’ Home. No individual health insurance policy delivered, issued for delivery or renewed in this state on or after October 1, 1988, may exclude coverage for services provided by the Veterans’ Home.

(P.A. 88-68; P.A. 90-243, S. 92; P.A. 04-169, S. 18.)

History: P.A. 90-243 substituted reference to health insurance policies for reference to hospital and medical expense policies and contracts and made technical grammatical change; Sec. 38-174ff transferred to Sec. 38a-502 in 1991; P.A. 04-169 changed the name of the Veterans’ Home and Hospital to the Veterans’ Home, effective June 1, 2004.

See Sec. 38a-529 for similar provisions re group policies.

Sec. 38a-503. (Formerly Sec. 38-174gg). Mandatory coverage for mammography, breast ultrasound and magnetic resonance imaging. Breast density information included in mammography report. (a)(1) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (10), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide benefits for mammographic examinations to any woman covered under the policy that are at least equal to the following minimum requirements: (A) A baseline mammogram for any woman who is thirty-five to thirty-nine years of age, inclusive; and (B) a mammogram every year for any woman who is forty years of age or older.

(2) Such policy shall provide additional benefits for:

(A) Comprehensive ultrasound screening of an entire breast or breasts if a mammogram demonstrates heterogeneous or dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology or if a woman is believed to be at increased risk for breast cancer due to family history or prior personal history of breast cancer, positive genetic testing or other indications as determined by a woman’s physician or advanced practice registered nurse; and

(B) Magnetic resonance imaging of an entire breast or breasts in accordance with guidelines established by the American Cancer Society.

(b) Benefits under this section shall be subject to any policy provisions that apply to other services covered by such policy.

(c) Each mammography report provided to a patient shall include information about breast density, based on the Breast Imaging Reporting and Data System established by the American College of Radiology. Where applicable, such report shall include the following notice: “If your mammogram demonstrates that you have dense breast tissue, which could hide small abnormalities, you might benefit from supplementary screening tests, which can include a breast ultrasound screening or a breast MRI examination, or both, depending on your individual risk factors. A report of your mammography results, which contains information about your breast density, has been sent to your physician’s office and you should contact your physician if you have any questions or concerns about this report.”.

(P.A. 88-124, S. 1; P.A. 90-243, S. 93; P.A. 01-171, S. 22; P.A. 05-69, S. 1; P.A. 06-38, S. 1; P.A. 09-41, S. 1; P.A. 11-67, S. 1; 11-171, S. 1; P.A. 12-150, S. 1.)

History: P.A. 90-243 substituted reference to health insurance policies for references to hospital or medical expense policies and contracts and specified applicability solely to individual policies; Sec. 38-174gg transferred to Sec. 38a-503 in 1991; P.A. 01-171 added “amended or continued” re policies in this state, substituted “October 1, 2001,” for “October 1, 1988,” re policy date, consolidated Subdivs. (2) and (3) to provide annual coverage for any woman who is forty or over rather than coverage every two years for women 40 to 49 and annually thereafter, and substituted “each” for “every”; P.A. 05-69 added Subsec. designators (a) and (b), amended Subsec. (a) to require benefits for comprehensive ultrasound screening for certain women if recommended by a physician, and made technical changes in Subsec. (b); P.A. 06-38 amended Subsec. (a) to require policy to provide additional benefits for comprehensive ultrasound screening of an entire breast or breasts if mammogram demonstrates heterogeneous or dense breast tissue based on the BIRAD System or if a woman is believed to be at increased risk for breast cancer due to family history or prior personal history of breast cancer, positive genetic testing or other indications determined by a physician or advanced practice registered nurse, eliminating reference to screening recommended by a physician for a woman classified as a category 2, 3, 4 or 5 under such system; P.A. 09-41 added Subsec. (c) re breast density information required to be provided to a patient and notice where applicable; P.A. 11-67 amended Subsec. (a) to add mandatory coverage for magnetic resonance imaging if a mammogram demonstrates heterogeneous or dense breast tissue or if a woman is believed to be at increased risk for breast cancer due to family or prior personal history, and to make technical changes, effective January 1, 2012; P.A. 11-171 amended Subsec. (a) to add mandatory coverage for magnetic resonance imaging in accordance with guidelines established by the American Cancer Society or the American College of Radiology, and to make technical changes, effective January 1, 2012; P.A. 12-150 amended Subsec. (a)(2) to delete “and magnetic resonance imaging” in Subpara. (A) and add “of an entire breast or breasts” and delete reference to American College of Radiology in Subpara. (B), amended Subsec. (c) to delete “On and after October 1, 2009”, and made technical changes, effective June 15, 2012.

See Sec. 38a-530 for similar provisions re group policies.

Sec. 38a-503a. Mandatory coverage for breast cancer survivors. (a) No individual health insurance plan, as defined in subdivision (1) of subsection (a) of section 38a-476, or insurance arrangement, as defined in subdivision (2) of subsection (a) of section 38a-476, may refuse to cover an individual health insurance applicant due to breast cancer if such applicant has remained free from breast cancer for at least five years prior to the applicant’s request for individual health insurance coverage. The individual health insurance carrier may require that the applicant submit to a physical examination.

(b) The provisions of this section shall apply to every health insurance plan or insurance arrangement issued, renewed or continued in this state on or after October 1, 1996. For purposes of this section, the date a plan or arrangement is continued shall be the anniversary date of the issuance of the plan or arrangement.

(P.A. 96-177, S. 4.)

See Sec. 38a-476(a) re breast cancer and preexisting conditions clauses.

See Sec. 38a-530a for similar provisions re group policies.

Sec. 38a-503b. Carriers to permit direct access to obstetrician-gynecologist. (a) As used in this section, “carrier” means each insurer, health care center, hospital service corporation, medical service corporation or other entity delivering, issuing for delivery, renewing, amending or continuing any individual health insurance policy in this state providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469.

(b) Each carrier shall permit a female enrollee direct access to a participating in-network obstetrician-gynecologist for any gynecological examination or care related to pregnancy and shall allow direct access to a participating in-network obstetrician-gynecologist for primary and preventive obstetric and gynecologic services required as a result of any gynecological examination or as a result of a gynecological condition. Such obstetric and gynecologic services include, but are not limited to, pap smear tests. The plan may require the participating in-network obstetrician-gynecologist to discuss such services and any treatment plan with the female enrollee’s primary care provider. Nothing in this section shall preclude access to an in-network nurse-midwife as licensed pursuant to sections 20-86c and 20-86g and in-network advanced practice registered nurses, as licensed pursuant to sections 20-93 and 20-94a for obstetrical and gynecological services within their scope of practice.

(c) Each carrier may allow a female enrollee to designate either a participating, in-network obstetrician-gynecologist or any other in-network physician designated by the carrier as a primary care provider, or both, and may offer the same choice to all female enrollees.

(P.A. 95-199, S. 1; P.A. 96-227, S. 14; P.A. 01-171, S. 18; P.A. 10-32, S. 120; P.A. 11-19, S. 49.)

History: P.A. 96-227 amended Subsec. (a) to include Subdiv. (12) in its citation to Sec. 38a-469; P.A. 01-171 amended Subsec. (b) to provide that “such obstetric and gynecologic services include, but are not limited to, pap smear tests”; P.A. 10-32 made a technical change in Subsec. (b), effective May 10, 2010; P.A. 11-19 inserted “or continuing” and made technical changes in Subsec. (a), effective January 1, 2012.

See Sec. 38a-530b for similar provisions re group policies.

Sec. 38a-503c. Mandatory coverage for maternity care. Notice required. (a) As used in this section, “carrier” means each insurer, health care center, hospital service corporation, medical service corporation or other entity delivering, issuing for delivery, renewing, amending or continuing any individual health insurance policy in this state providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469.

(b) Each individual health insurance carrier that offers maternity benefits shall provide coverage of a minimum of forty-eight hours of inpatient care for a mother and her newborn infant following a vaginal delivery and a minimum of ninety-six hours of inpatient care for a mother and her newborn infant following a caesarean delivery. The time periods shall commence at the time of delivery.

(c) Any decision to shorten the length of inpatient stay to less than that provided under subsection (b) of this section shall be made by the attending health care providers after conferring with the mother.

(d) If a mother and newborn are discharged pursuant to subsection (c) of this section, prior to the inpatient length of stay provided under subsection (b) of this section, coverage shall be provided for a follow-up visit within forty-eight hours of discharge and an additional follow-up visit within seven days of discharge. Such follow-up services shall include, but not be limited to, physical assessment of the newborn, parent education, assistance and training in breast or bottle feeding, assessment of the home support system and the performance of any medically necessary and appropriate clinical tests. Such services shall be consistent with protocols and guidelines developed by attending providers or by national pediatric, obstetric and nursing professional organizations for these services and shall be provided by qualified health care personnel trained in postpartum maternal and newborn pediatric care.

(e) Each individual health insurance carrier shall provide notice to policyholders regarding the coverage required under this section. The notice shall be in writing and shall be transmitted at the earliest of either the next mailing to the policyholder, the yearly summary of benefits sent to the policyholder or January 1, 1997.

(P.A. 96-177, S. 1, 6; P.A. 11-19, S. 51.)

History: P.A. 96-177 effective May 24, 1996; P.A. 11-19 inserted “or continuing” and made technical changes in Subsec. (a), effective January 1, 2012.

See Sec. 38a-530c for similar provisions re group policies.

Sec. 38a-503d. Mandatory coverage for mastectomy care. Termination of provider contract prohibited. (a) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (10), (11) and (12) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state shall provide coverage for at least forty-eight hours of inpatient care following a mastectomy or lymph node dissection, and shall provide coverage for a longer period of inpatient care if such care is recommended by the patient’s treating physician after conferring with the patient. No such insurance policy may require mastectomy surgery or lymph node dissection to be performed on an outpatient basis. Outpatient surgery or shorter inpatient care is allowable under this section if the patient’s treating physician recommends such outpatient surgery or shorter inpatient care after conferring with the patient.

(b) No individual health insurance carrier may terminate the services of, require additional documentation from, require additional utilization review, reduce payments or otherwise penalize or provide financial disincentives to any attending health care provider on the basis that the provider orders care consistent with the provisions of this section.

(P.A. 97-198, S. 1, 5; P.A. 11-19, S. 8.)

History: P.A. 97-198 effective July 1, 1997; P.A. 11-19 made a technical change in Subsec. (a).

See Sec. 38a-530d for similar provisions re group policies.

Sec. 38a-503e. Mandatory coverage for prescription contraceptives. (a) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state that provides coverage for outpatient prescription drugs approved by the federal Food and Drug Administration shall not exclude coverage for prescription contraceptive methods approved by the federal Food and Drug Administration.

(b) (1) Notwithstanding any other provision of this section, any insurance company, hospital or medical service corporation, or health care center may issue to a religious employer an individual health insurance policy that excludes coverage for prescription contraceptive methods which are contrary to the religious employer’s bona fide religious tenets.

(2) Notwithstanding any other provision of this section, upon the written request of an individual who states in writing that prescription contraceptive methods are contrary to such individual’s religious or moral beliefs, any insurance company, hospital or medical service corporation, or health care center may issue to the individual an individual health insurance policy that excludes coverage for prescription contraceptive methods.

(c) Any health insurance policy issued pursuant to subsection (b) of this section shall provide written notice to each insured or prospective insured that prescription contraceptive methods are excluded from coverage pursuant to said subsection. Such notice shall appear, in not less than ten-point type, in the policy, application and sales brochure for such policy.

(d) Nothing in this section shall be construed as authorizing an individual health insurance policy to exclude coverage for prescription drugs ordered by a health care provider with prescriptive authority for reasons other than contraceptive purposes.

(e) Notwithstanding any other provision of this section, any insurance company, hospital or medical service corporation, or health care center which is owned, operated or substantially controlled by a religious organization which has religious or moral tenets which conflict with the requirements of this section may provide for the coverage of prescription contraceptive methods as required under this section through another such entity offering a limited benefit plan. The cost, terms and availability of such coverage shall not differ from the cost, terms and availability of other prescription coverage offered to the insured.

(f) As used in this section, “religious employer” means an employer that is a “qualified church-controlled organization” as defined in 26 USC 3121 or a church-affiliated organization.

(P.A. 99-79, S. 1; P.A. 11-19, S. 53.)

History: P.A. 11-19 inserted “amended” and made a technical change in Subsec. (a), effective January 1, 2012.

See Sec. 38a-530e for similar provisions re group policies.

Sec. 38a-504. (Formerly Sec. 38-262i). Mandatory coverage for treatment of tumors and leukemia. Mandatory coverage for reconstructive surgery, prosthesis, chemotherapy and wigs. Orally administered anticancer medications. (a) Each insurance company, hospital service corporation, medical service corporation, health care center or fraternal benefit society that delivers, issues for delivery, renews, amends or continues in this state individual health insurance policies providing coverage of the type specified in subdivisions (1), (2), (4), (10), (11) and (12) of section 38a-469, shall provide coverage under such policies for the surgical removal of tumors and treatment of leukemia, including outpatient chemotherapy, reconstructive surgery, cost of any nondental prosthesis including any maxillo-facial prosthesis used to replace anatomic structures lost during treatment for head and neck tumors or additional appliances essential for the support of such prosthesis, outpatient chemotherapy following surgical procedure in connection with the treatment of tumors, and a wig if prescribed by a licensed oncologist for a patient who suffers hair loss as a result of chemotherapy. Such benefits shall be subject to the same terms and conditions applicable to all other benefits under such policies.

(b) Except as provided in subsection (c) of this section, the coverage required by subsection (a) of this section shall provide at least a yearly benefit of five hundred dollars for the surgical removal of tumors, five hundred dollars for reconstructive surgery, five hundred dollars for outpatient chemotherapy, three hundred fifty dollars for a wig and three hundred dollars for a nondental prosthesis, except that for purposes of the surgical removal of breasts due to tumors the yearly benefit for such prosthesis shall be at least three hundred dollars for each breast removed.

(c) The coverage required by subsection (a) of this section shall provide benefits for the reasonable costs of reconstructive surgery on each breast on which a mastectomy has been performed, and reconstructive surgery on a nondiseased breast to produce a symmetrical appearance. Such benefits shall be subject to the same terms and conditions applicable to all other benefits under such policies. For the purposes of this subsection, reconstructive surgery includes, but is not limited to, augmentation mammoplasty, reduction mammoplasty and mastopexy.

(d) (1) Each policy of the type specified in subsection (a) of this section that provides coverage for intravenously administered and orally administered anticancer medications used to kill or slow the growth of cancerous cells that are prescribed by a prescribing practitioner, as defined in section 20-571, shall provide coverage for orally administered anticancer medications on a basis that is no less favorable than intravenously administered anticancer medications.

(2) No insurance company, hospital service corporation, medical service corporation, health care center or fraternal benefit society that delivers, issues for delivery, renews, amends or continues in this state a policy of the type specified in subsection (a) of this section shall reclassify such anticancer medications or increase the coinsurance, copayment, deductible or other out-of-pocket expense imposed under such policy for such medications to achieve compliance with this subsection.

(P.A. 79-327, S. 2; P.A. 86-54; P.A. 87-40; 87-275, S. 2; P.A. 90-243, S. 94; P.A. 97-198, S. 3, 5; P.A. 98-27, S. 17; P.A. 04-34, S. 1; P.A. 10-5, S. 24; 10-63, S. 1; P.A. 11-19, S. 10.)

History: P.A. 86-54 clarified the section by limiting its applicability to individual and group medical expense insurance policies and contract plans, rather than to all individual and group health insurance policies and contract plans; P.A. 87-40 amended Subsec. (c) to increase the minimum coverage requirement for prosthesis from $200 to $300; P.A. 87-275 amended Subsec. (c) to provide that the yearly benefit for prosthesis shall be at least $300 for each breast surgically removed due to tumors; P.A. 90-243 deleted former Subsec. (a) re group coverages, relettered the remaining Subsecs., added references to health care centers, substituted references to health insurance policies for references to medical expense policies or contracts; Sec. 38-262i transferred to Sec. 38a-504 in 1991; P.A. 97-198 added exception in Subsec. (b) and added new Subsec. (c) re breast reconstruction after mastectomy, effective July 1, 1997; P.A. 98-27 amended Subsec. (a) to delete reference to Sec. 38a-469(6); P.A. 04-34 amended Subsec. (a) to substitute “Each” for “Any” and require coverage for a wig if prescribed for a patient who suffers hair loss as a result of chemotherapy and amended Subsec. (b) to require a yearly benefit of $350 for a wig; P.A. 10-5 made technical changes in Subsecs. (a) and (b), effective January 1, 2011; P.A. 10-63 made technical changes in Subsecs. (a) and (b), and added Subsec. (d) re orally administered anticancer medications, effective January 1, 2011; P.A. 11-19 made technical changes in Subsec. (d).

See Secs. 38a-199 to 38a-209, inclusive, re hospital service corporations.

See Secs. 38a-214 to 38a-225, inclusive, re medical service corporations.

See Sec. 38a-542 for similar provisions re group policies.

See Secs. 38a-595 to 38a-626, inclusive, 38a-631 to 38a-640, inclusive, and 38a-800 re fraternal benefit societies.

Sec. 38a-504a. Coverage for routine patient care costs associated with certain clinical trials. Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for the routine patient care costs, as defined in section 38a-504d, associated with clinical trials, in accordance with sections 38a-504b to 38a-504g, inclusive. As used in this section and sections 38a-504b to 38a-504g, inclusive, “clinical trial” means an organized, systematic, scientific study of therapies, tests or other clinical interventions for purposes of treatment or palliation or therapeutic intervention for the prevention of cancer or disabling or life-threatening chronic diseases in human beings.

(P.A. 01-171, S. 8, 25; P.A. 11-19, S. 57; 11-172, S. 1.)

History: P.A. 01-171 effective January 1, 2002; P.A. 11-19 inserted “amended or continued”, redefined “cancer clinical trial” and made a technical change, effective January 1, 2012; P.A. 11-172 inserted “amended or continued”, replaced reference to cancer clinical trials with reference to clinical trials, changed defined term from “cancer clinical trial” to “clinical trial” and redefined same, and made technical changes, effective January 1, 2012.

See Sec. 38a-542a for similar provisions re group policies.

Sec. 38a-504b. Clinical trial criteria. A clinical trial for the prevention of cancer shall be eligible for coverage only if it involves a therapeutic intervention, is a phase III clinical trial approved by one of the entities identified in this section, and is conducted at multiple institutions. In order to be eligible for coverage of routine patient care costs, as defined in section 38a-504d, a clinical trial shall be (1) conducted under the auspices of an independent peer-reviewed protocol that has been reviewed and approved by: (A) One of the National Institutes of Health; (B) a National Cancer Institute affiliated cooperative group; (C) the federal Food and Drug Administration as part of an investigational new drug or device application or exemption; or (D) the federal Department of Defense or Veterans Affairs; or (2) qualified to receive Medicare coverage of its routine costs under the Medicare Clinical Trial Policy established under the September 19, 2000, Medicare National Coverage Determination, as amended from time to time. Nothing in sections 38a-504a to 38a-504g, inclusive, shall be construed to require coverage for any single institution clinical trial conducted solely under the approval of the institutional review board of an institution, or any trial that is no longer approved by an entity identified in subparagraph (A), (B), (C) or (D) of subdivision (1) of this section.

(P.A. 01-171, S. 9, 25; P.A. 11-19, S. 58; 11-172, S. 2.)

History: P.A. 01-171 effective January 1, 2002; P.A. 11-19 added provision limiting eligibility of clinical trial for the prevention of cancer, effective January 1, 2012; P.A. 11-172 replaced references to cancer clinical trial with references to clinical trial, designated existing clinical trial criteria as Subdiv. (1) and amended same to insert “application or” re investigational new drug or device, added Subdiv. (2) re Medicare qualification, and made technical changes, effective January 1, 2012.

See Sec. 38a-542b for similar provisions re group policies.

Sec. 38a-504c. Evidence and information re eligibility for clinical trial. No coverage required for otherwise reimbursable costs. In order to be eligible for coverage of routine patient care costs, as defined in section 38a-504d, the insurer, health care center or plan administrator may require that the person or entity seeking coverage for the clinical trial provide: (1) Evidence satisfactory to the insurer, health care center or plan administrator that the insured person receiving coverage meets all of the patient selection criteria for the clinical trial, including credible evidence in the form of clinical or preclinical data showing that the clinical trial is likely to have a benefit for the insured person that is commensurate with the risks of participation in the clinical trial to treat the person’s condition; (2) evidence that the appropriate informed consent has been received from the insured person; (3) copies of any medical records, protocols, test results or other clinical information used by the physician or institution seeking to enroll the insured person in the clinical trial; (4) a summary of the anticipated routine patient care costs in excess of the costs for standard treatment; (5) information from the physician or institution seeking to enroll the insured person in the clinical trial regarding those items, including any routine patient care costs, that are eligible for reimbursement by an entity other than the insurer or health care center, including the entity sponsoring the clinical trial; and (6) any additional information that may be reasonably required for the review of a request for coverage of the clinical trial. The health plan or insurer shall request any additional information about a clinical trial not later than five business days after receiving a request for coverage from an insured person or a physician seeking to enroll an insured person in a clinical trial. Nothing in sections 38a-504a to 38a-504g, inclusive, shall be construed to require the insurer or health care center to provide coverage for routine patient care costs that are eligible for reimbursement by an entity other than the insurer, including the entity sponsoring the clinical trial.

(P.A. 01-171, S. 10, 25; P.A. 11-19, S. 59; 11-172, S. 3.)

History: P.A. 01-171 effective January 1, 2002; P.A. 11-19 made technical changes, effective January 1, 2012; P.A. 11-172 replaced references to cancer clinical trial with references to clinical trial and made technical changes, effective January 1, 2012.

See Sec. 38a-542c for similar provisions re group policies.

Sec. 38a-504d. Clinical trials: Routine patient care costs. (a) For purposes of sections 38a-504a to 38a-504g, inclusive, “routine patient care costs” means: (1) Medically necessary health care services that are incurred as a result of the treatment being provided to the insured person for purposes of the clinical trial that would otherwise be covered if such services were not rendered pursuant to a clinical trial. Such services shall include those rendered by a physician, diagnostic or laboratory tests, hospitalization or other services provided to the insured person during the course of treatment in the clinical trial for a condition, or one of its complications, that is consistent with the usual and customary standard of care and would be covered if the insured person were not enrolled in a clinical trial. Such hospitalization shall include treatment at an out-of-network facility if such treatment is not available in-network and not eligible for reimbursement by the sponsors of such clinical trial, and (2) costs incurred for drugs provided to the insured person, in accordance with section 38a-492b, provided such drugs have been approved for sale by the federal Food and Drug Administration.

(b) Routine patient care costs shall be subject to the terms, conditions, restrictions, exclusions and limitations of the contract or certificate of insurance between the insured person and the insurer or health plan, including limitations on out-of-network care, except that treatment at an out-of-network hospital as provided in subdivision (1) of subsection (a) of this section shall be made available by the out-of-network hospital and the insurer or health care center at no greater cost to the insured person than if such treatment was available in-network. The insurer or health care center may require that any routine tests or services required under the clinical trial protocol be performed by providers or institutions under contract with the insurer or health care center.

(c) Notwithstanding the provisions of subsection (a) of this section, routine patient care costs shall not include: (1) The cost of an investigational new drug or device that has not been approved for market for any indication by the federal Food and Drug Administration; (2) the cost of a non-health-care service that an insured person may be required to receive as a result of the treatment being provided for the purposes of the clinical trial; (3) facility, ancillary, professional services and drug costs that are paid for by grants or funding for the clinical trial; (4) costs of services that (A) are inconsistent with widely accepted and established regional or national standards of care for a particular diagnosis, or (B) are performed specifically to meet the requirements of the clinical trial; (5) costs that would not be covered under the insured person’s policy for noninvestigational treatments, including, but not limited to, items excluded from coverage under the insured person’s contract with the insurer or health plan; and (6) transportation, lodging, food or any other expenses associated with travel to or from a facility providing the clinical trial, for the insured person or any family member or companion.

(P.A. 01-171, S. 11, 25; P.A. 07-67, S. 1; P.A. 11-19, S. 60; 11-172, S. 4.)

History: P.A. 01-171 effective January 1, 2002; P.A. 07-67 amended Subsec. (a)(1) to require that hospitalization include treatment at an out-of-network facility if treatment is not available in-network and not eligible for reimbursement by sponsors of clinical trial, and amended Subsec. (b) to require out-of-network hospitalization to be made available at the in-network level of benefits under the policy or contract, effective May 30, 2007; P.A. 11-19 amended Subsec. (a) to replace “38a-518b” with “38a-492b” in Subdiv. (2) and make technical changes, effective January 1, 2012; P.A. 11-172 replaced references to cancer clinical trial with references to clinical trial, replaced “38a-518b” with “38a-492b” in Subsec. (a)(2) and made technical changes, effective January 1, 2012.

See Sec. 38a-542d for similar provisions re group provisions.

Sec. 38a-504e. Clinical trials: Billing. Payments. (a) Providers, hospitals and institutions that provide routine patient care services as set forth in subsection (a) of section 38a-504d as part of a clinical trial that meets the requirements of sections 38a-504a to 38a-504g, inclusive, and is approved for coverage by the insurer or health care center shall not bill the insurer or health care center or the insured person for any facility, ancillary or professional services or costs that are not routine patient care services as set forth in subsection (a) of section 38a-504d or for any product or service that is paid by the entity sponsoring or funding the clinical trial.

(b) Providers, hospitals, institutions and insured persons may appeal a health plan’s denials of payment for services only to the extent permitted by the contract between the insurer or health care center and the provider, hospital or institution.

(c) Providers, hospitals or institutions that have contracts with the insurer or health care center to render covered routine patient care services to insured persons as part of a clinical trial shall not bill the insured person for the cost of any covered routine patient care service.

(d) Providers, hospitals or institutions that do not have a contract with the insurer or health care center to render covered routine patient care services to insured persons as part of a clinical trial shall not bill the insured person for the cost of any covered routine patient care service.

(e) Nothing in this section shall be construed to prohibit a provider, hospital or institution from collecting a deductible or copayment as set forth in the insured person’s contract for any covered routine patient care service.

(f) Pursuant to subsection (b) of section 38a-504d, insurers or health care centers shall be required to pay providers, hospitals and institutions that do not have a contract with the insurer or health care center to render covered routine patient care services to insured persons the lesser of (1) the lowest contracted per diem, fee schedule rate or case rate that the insurer or health care center pays to any participating provider in the state of Connecticut for similar in-network services, or (2) the billed charges. Providers, hospitals or institutions shall not collect any amount more than the total amount paid by the insurer or health care center and the insured person in the form of a deductible or copayment set forth in the insured person’s contract. Such amount shall be deemed by the provider, hospital or institution to be payment in full.

(P.A. 01-171, S. 12, 25; P.A. 11-172, S. 5.)

History: P.A. 01-171 effective January 1, 2002; P.A. 11-172 replaced references to cancer clinical trial with references to clinical trial and, in Subsecs. (c), (d) and (f), changed “may not” to “shall not”, effective January 1, 2012.

See Sec. 38a-542e for similar provisions re group policies.

Sec. 38a-504f. Clinical trials: Standardized forms. Time frame for coverage determinations. Appeals. Regulations. (a)(1) For purposes of cancer clinical trials, the Insurance Department, in cooperation with the Connecticut Oncology Association, the American Cancer Society, the Connecticut Association of Health Plans and Anthem Blue Cross of Connecticut, shall develop a standardized form that all providers, hospitals and institutions shall submit to the insurer or health care center when seeking to enroll an insured person in a cancer clinical trial. An insurer or health care center shall not substitute any other approval request form for the form developed by the department, except that any insurer or health care center that has entered into an agreement to provide coverage for cancer clinical trials approved pursuant to section 38a-504g may use the form or process established by such agreement.

(2) For purposes of clinical trials other than cancer clinical trials, the Insurance Department, in cooperation with at least one state nonprofit research or advocacy organization concerned with the subject of the clinical trial, at least one national nonprofit research or advocacy organization concerned with the subject of the clinical trial, the Connecticut Association of Health Plans and Anthem Blue Cross of Connecticut, shall develop a standardized form that all providers, hospitals and institutions shall submit to the insurer or health care center when seeking to enroll an insured person in a clinical trial. An insurer or health care center shall not substitute any other approval request form for the form developed by the department, except that any insurer or health care center that has entered into an agreement to provide coverage for clinical trials approved pursuant to section 38a-504g may use the form or process established by such agreement.

(b) Any insurer or health care center that receives the department form from a provider, hospital or institution seeking coverage for the routine patient care costs of an insured person in a clinical trial shall approve or deny coverage for such services not later than five business days after receiving such request and any other reasonable supporting materials requested by the insurer or health plan pursuant to section 38a-504c, except that an insurer or health care center that utilizes independent experts to review such requests shall respond not later than ten business days after receiving such request and supporting materials.

(c) The insured, or the provider with the insured’s written consent, may appeal any denial of coverage for medical necessity to an external, independent review pursuant to section 38a-591g. Such external review shall be conducted by a properly qualified review agent whom the department has determined does not have a conflict of interest regarding the clinical trial.

(d) The Insurance Commissioner shall adopt regulations, in accordance with chapter 54, to implement the provisions of this section.

(P.A. 01-171, S. 13, 25; P.A. 11-19, S. 61; 11-58, S. 83; 11-172, S. 6.)

History: P.A. 01-171 effective January 1, 2002; P.A. 11-19 made technical changes in Subsec. (b), effective January 1, 2012; P.A. 11-58 replaced reference to Sec. 38a-478n with “section 38a-591g” in Subsec. (c), effective July 1, 2011; P.A. 11-172 amended Subsec. (a) by designating existing provisions as Subdiv. (1) and amending same to change “may not” to “shall not” and by adding Subdiv. (2) re standardized form for clinical trials other than cancer clinical trials, amended Subsec. (b) by replacing references to cancer clinical trial with references to clinical trial, deleting provision re time period for approval or denial of coverage for phase III clinical trials for prevention of cancer and by making technical changes, and amended Subsec. (c) by replacing reference to cancer clinical trial with reference to clinical trial, effective January 1, 2012.

See Sec. 38a-542f for similar provisions re group policies.

Sec. 38a-504g. Clinical trials: Submission and certification of policy forms. (a) Any insurer or health care center with coverage policies for care in clinical trials shall submit such policies to the Insurance Department for evaluation and approval. The department shall certify whether the insurer’s or health care center’s coverage policy for routine patient care costs associated with clinical trials is substantially equivalent to the requirements of sections 38a-504a to 38a-504f, inclusive. If the department finds that such coverage is substantially equivalent to the requirements of sections 38a-504a to 38a-504f, inclusive, the insurer or health care center shall be exempt from the provisions of sections 38a-504a to 38a-504f, inclusive.

(b) Any such insurer or health care center shall report annually, in writing, to the department that there have been no changes in the policy as certified by the department. If there has been any change in the policy, the insurer or health care center shall resubmit its policy for certification by the department.

(c) Any insurer or health care center coverage policy found by the department not to be substantially equivalent to the requirements of sections 38a-504a to 38a-504f, inclusive, shall abide by the requirements of sections 38a-504a to 38a-504f, inclusive, until the insurer or health care center has received such certification by the department.

(P.A. 01-171, S. 14, 25; P.A. 11-172, S. 7; P.A. 12-145, S. 16.)

History: P.A. 01-171 effective January 1, 2002; P.A. 11-172 replaced references to cancer clinical trials with references to clinical trials in Subsec. (a), effective January 1, 2012; P.A. 12-145 replaced references to Sec. 38a-504g with references to Sec. 38a-504f, effective June 15, 2012.

See Sec. 38a-542g for similar provisions re group policies.

Sec. 38a-505. (Formerly Sec. 38-378). Insurance Commissioner’s powers concerning comprehensive health care plans. Notification to purchasers of policy. In order to provide reasonable simplification of terms and coverages of individual health insurance policies, to facilitate public understanding and comparison, to eliminate provisions which may be misleading or unreasonably confusing in connection with either the purchase of such coverage or with the settlement of claims and to provide for full disclosure in the sale of such coverages:

(a) The commissioner shall issue regulations to establish specific standards for policy provisions used in individual health insurance policies, but not including group conversion policies, which shall be in addition to and in accordance with sections 38a-80, 38a-321 to 38a-324, inclusive, 38a-326, 38a-329, 38a-334 to 38a-336a, inclusive, 38a-338 to 38a-358, inclusive, 38a-470 to 38a-472, inclusive, 38a-475, 38a-480 to 38a-503, inclusive, 38a-507, 38a-514, 38a-519, 38a-523, 38a-531, 38a-577 to 38a-590, inclusive, and 38a-802 to 38a-810, inclusive, and other applicable laws of this state which may cover the terms of renewability, initial and subsequent conditions of eligibility, nonduplication of coverage provisions, coverage of dependents, termination of insurance, probationary periods, limitations, exceptions, reductions, elimination periods, requirements for replacements, recurrent conditions, preexisting conditions, and the definition of the terms hospital, accident, sickness, injury, physician, accidental means, total disability, permanent disability, partial disability, nervous disorders, guaranteed renewable, and noncancellable.

(b) The commissioner shall adopt regulations, in accordance with chapter 54, that specify prohibited policy provisions not otherwise specifically authorized by statute which in the opinion of the commissioner are unjust, unfair or unfairly discriminatory to the policyholder, any person insured under the policy, or any beneficiary.

(c) The commissioner shall adopt regulations, in accordance with chapter 54, to establish minimum standards for benefits under each of the following categories of coverage in individual policies, other than conversion policies issued pursuant to a contractual conversion privilege under a group policy: Basic hospital expense coverage, basic medical-surgical expense coverage, hospital confinement indemnity coverage, major medical expense coverage, disability income protection coverage, accident only coverage, specified accident coverage and specified disease coverage.

(d) Nothing in this section shall preclude the issuance of any policy which combines two or more of the categories of coverage enumerated in subsection (c), except that specified accident coverage shall not be combined with any other category of coverage. The commissioner shall prescribe the method of identification of policies based upon coverage provided.

(e) No policy shall be delivered or issued for delivery in this state which does not meet the prescribed minimum standards for the categories of coverage listed in subsection (c), provided nothing in this section shall preclude the issuance or delivery of any policy which does not meet such prescribed minimum standards of coverage so long as such policy is clearly identified as not meeting such prescribed standards.

(f) No such policy shall be delivered in this state unless: (1) An outline of coverage described herein accompanies the policy or (2) the outline of coverage described in this section is delivered to the applicant at the time application is made and acknowledgment of receipt of certificate of delivery of such outline is provided the carrier with the application. In the event the policy is issued on a basis other than that applied for, the outline of coverage properly describing the policy shall accompany the policy when it is delivered. The outline of coverage shall include: (A) A statement identifying the applicable category or categories of coverage provided by the policy in accordance with this section; (B) a description of the principal benefits and coverage provided in the policy; (C) a statement of the exceptions, reductions and limitations contained in the policy or contract; (D) a statement of the renewal provisions including any reservation by the carrier of a right to change premiums; and (E) a statement that the outline is a summary of the policy issued or applied for and that the policy should be consulted to determine governing contractual provisions.

(g) Notwithstanding the provisions of sections 38a-80, 38a-321 to 38a-324, inclusive, 38a-326, 38a-329, 38a-334 to 38a-336a, inclusive, 38a-338 to 38a-358, inclusive, 38a-470 to 38a-472, inclusive, 38a-475, 38a-480 to 38a-503, inclusive, 38a-507, 38a-514, 38a-519, 38a-523, 38a-531, 38a-577 to 38a-590, inclusive, and 38a-802 to 38a-810, inclusive, if a carrier elects to use a simplified application form, with or without any questions as to the applicant’s health at the time of application, but without any questions concerning the insured’s health history or medical treatment history, the policy shall cover loss developing after twelve months from any preexisting condition not specifically excluded from coverage by the terms of the policy and, except as so provided, the policy shall not include wording that would permit a defense based upon preexisting conditions.

(h) Regulations promulgated pursuant to this section shall specify an effective date applicable to policy and benefit riders delivered or issued for delivery in this state on and after such effective date which shall not be less than one hundred eighty days after the date of adoption or promulgation.

(P.A. 75-616, S. 8, 12; P.A. 76-399, S. 4, 5; P.A. 90-200, S. 2; 90-243, S. 155; P.A. 93-297, S. 22, 23, 29; P.A. 08-181, S. 5.)

History: P.A. 76-399 clarified prohibition of specific disease policies in Subsec. (c) to specify “riders and benefits” and “whether issued on a group or individual basis”; P.A. 90-200 amended Subsec. (c) to allow the issuance of specified disease policies for accelerated benefits of life insurance policies provided the commissioner adopts regulations re minimum standards for issuance; P.A. 90-243 substituted “health insurance policies” for “accident and sickness contracts” and deleted the reference to “contracts”; Sec. 38-378 transferred to Sec. 38a-505 in 1991; P.A. 93-297 added references to Sec. 38a-336a in Subsecs. (a) and (g), effective January 1, 1994, and applicable to acts or omissions occurring on or after said date; P.A. 08-181 amended Subsec. (c) by deleting prohibition on sale of specified disease policies, riders and benefits and adding specified disease coverage to list of individual policies for which commissioner is directed to adopt regulations, effective June 12, 2008.

Sec. 38a-506. (Formerly Sec. 38-173). Penalty. Any insurer, hospital or medical service corporation, health care center or fraternal benefit society, or any officer or agent thereof, delivering or issuing for delivery to any person in this state any policy in violation of any of the provisions of sections 38a-481 to 38a-488, inclusive, shall be fined not more than ten thousand dollars for each offense, and the commissioner may revoke the license of any foreign or alien insurer, or any agent thereof, violating any of said provisions.

(1949 Rev., S. 6189; 1951, S. 2843d; P.A. 90-243, S. 95; P.A. 08-178, S. 16.)

History: P.A. 90-243 applied provisions to hospital or medical service corporations, health care centers, and fraternal benefit societies and substituted “foreign” for “nonresident” and “alien” for “foreign” insurance companies; Sec. 38-173 transferred to Sec. 38a-506 in 1991; P.A. 08-178 increased maximum fine from $500 to $10,000 per offense.

Sec. 38a-507. Coverage for services performed by chiropractors. Each individual health insurance policy delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for services rendered by a chiropractor licensed under chapter 372 to the same extent coverage is provided for services rendered by a physician, if such chiropractic services (1) treat a condition covered under such policy, and (2) are within those services a chiropractor is licensed to perform.

(P.A. 89-112; P.A. 90-243, S. 176; P.A. 11-19, S. 55.)

History: P.A. 90-243 substituted “health insurance policy” for “group hospital”, “medical expense insurance policy” and “individual or group hospital or medical service plan” and deleted references to “contract”; P.A. 11-19 inserted “amended or continued” and made technical changes, effective January 1, 2012.

See Sec. 38a-534 for similar provisions re group policies.

Sec. 38a-508. Coverage for adopted children. (a) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state shall provide coverage for a child legally placed for adoption with the insured or subscriber who is an adoptive parent or a prospective adoptive parent, even though the adoption has not been finalized, provided the child lives in the household of such insured or subscriber and the child is dependent upon such person for support and maintenance.

(b) Coverage for such child legally placed for adoption shall consist of coverage for injury and sickness including necessary care and treatment of medically diagnosed congenital defects and birth abnormalities within the limits of the policy.

(c) If payment of a specific premium or subscription fee is required to provide coverage for a child legally placed for adoption with the insured or subscriber who is an adoptive parent or a prospective adoptive parent, the policy or contract may require that notification of acceptance of such child and payment of the required premium or fees be furnished to the insurer, hospital or medical service corporation or health care center within thirty-one days after the acceptance of such child in order to continue coverage beyond such thirty-one-day period, provided failure to furnish such notice or pay such premium or fees shall not prejudice any claim originating within such thirty-one-day period.

(d) Such policy (1) shall cover such child legally placed for adoption on the same basis as other dependents, and (2) may not contain any provision concerning preexisting conditions, insurability, eligibility or health underwriting approval for a child legally placed for adoption, except that an insurer, hospital or medical service corporation or health care center may require health underwriting for a child legally placed for adoption if a required premium or subscription fee and completed application materials are not provided to the insurer, hospital or medical service corporation or health care center before the expiration of the thirty-one-day period following the date the child was legally placed for adoption.

(P.A. 91-97, S. 1; P.A. 02-96, S. 1; P.A. 03-70, S. 1.)

History: P.A. 02-96 amended Subsec. (a) to substitute “each” for “every” and “amended, renewed or continued in this state” for “amended or renewed in this state on or after October 1, 1991,” and added Subsec. (d) re coverage and prohibited provisions; P.A. 03-70 amended Subsec. (d) to add exception re health underwriting if required premium or subscription fee and completed application materials are not provided before expiration of thirty-one-day period.

See Sec. 38a-549 for similar provisions re group policies.

Sec. 38a-509. Mandatory coverage for infertility diagnosis and treatment. Limitations. (a) Subject to the limitations set forth in subsection (b) of this section and except as provided in subsection (c) of this section, each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state on or after October 1, 2005, shall provide coverage for the medically necessary expenses of the diagnosis and treatment of infertility, including, but not limited to, ovulation induction, intrauterine insemination, in-vitro fertilization, uterine embryo lavage, embryo transfer, gamete intra-fallopian transfer, zygote intra-fallopian transfer and low tubal ovum transfer. For purposes of this section, “infertility” means the condition of a presumably healthy individual who is unable to conceive or produce conception or sustain a successful pregnancy during a one-year period.

(b) Such policy may:

(1) Limit such coverage to an individual until the date of such individual’s fortieth birthday;

(2) Limit such coverage for ovulation induction to a lifetime maximum benefit of four cycles;

(3) Limit such coverage for intrauterine insemination to a lifetime maximum benefit of three cycles;

(4) Limit lifetime benefits to a maximum of two cycles, with not more than two embryo implantations per cycle, for in-vitro fertilization, gamete intra-fallopian transfer, zygote intra-fallopian transfer or low tubal ovum transfer, provided each such fertilization or transfer shall be credited toward such maximum as one cycle;

(5) Limit coverage for in-vitro fertilization, gamete intra-fallopian transfer, zygote intra-fallopian transfer and low tubal ovum transfer to those individuals who have been unable to conceive or produce conception or sustain a successful pregnancy through less expensive and medically viable infertility treatment or procedures covered under such policy. Nothing in this subdivision shall be construed to deny the coverage required by this section to any individual who foregoes a particular infertility treatment or procedure if the individual’s physician determines that such treatment or procedure is likely to be unsuccessful;

(6) Require that covered infertility treatment or procedures be performed at facilities that conform to the standards and guidelines developed by the American Society of Reproductive Medicine or the Society of Reproductive Endocrinology and Infertility;

(7) Limit coverage to individuals who have maintained coverage under such policy for at least twelve months; and

(8) Require disclosure by the individual seeking such coverage to such individual’s existing health insurance carrier of any previous infertility treatment or procedures for which such individual received coverage under a different health insurance policy. Such disclosure shall be made on a form and in the manner prescribed by the Insurance Commissioner.

(c) (1) Any insurance company, hospital or medical service corporation, or health care center may issue to a religious employer an individual health insurance policy that excludes coverage for methods of diagnosis and treatment of infertility that are contrary to the religious employer’s bona fide religious tenets.

(2) Upon the written request of an individual who states in writing that methods of diagnosis and treatment of infertility are contrary to such individual’s religious or moral beliefs, any insurance company, hospital or medical service corporation, or health care center may issue to or on behalf of the individual a policy or rider thereto that excludes coverage for such methods.

(d) Any health insurance policy issued pursuant to subsection (c) of this section shall provide written notice to each insured or prospective insured that methods of diagnosis and treatment of infertility are excluded from coverage pursuant to said subsection. Such notice shall appear, in not less than ten-point type, in the policy, application and sales brochure for such policy.

(e) As used in this section, “religious employer” means an employer that is a “qualified church-controlled organization”, as defined in 26 USC 3121 or a church-affiliated organization.

(P.A. 05-196, S. 1.)

See Sec. 38a-536 for similar provisions re group policies.

Sec. 38a-510. Prescription drug coverage. Mail order pharmacies. (a) No health insurance policy issued on an individual basis, whether issued by an insurance company, a hospital service corporation, a medical service corporation or a health care center, which provides coverage for prescription drugs may require any person covered under such policy to obtain prescription drugs from a mail order pharmacy as a condition of obtaining benefits for such drugs.

(b) The provisions of this section shall apply to any such policy delivered, issued for delivery, renewed, amended or continued in this state on or after July 1, 2005.

(P.A. 05-233, S. 1.)

History: P.A. 05-233 effective July 1, 2005.

See Sec. 38a-544 for similar provisions re group policies.

Sec. 38a-511. Copayments re in-network imaging services. (a) No health insurer, health care center, hospital service corporation, medical service corporation or fraternal benefit society that provides coverage under an individual health insurance policy or contract for magnetic resonance imaging or computed axial tomography may (1) require total copayments in excess of three hundred seventy-five dollars for all such in-network imaging services combined annually, or (2) require a copayment in excess of seventy-five dollars for each in-network magnetic resonance imaging or computed axial tomography, provided the physician ordering the radiological services and the physician rendering such services are not the same person or are not participating in the same group practice.

(b) No health insurer, health care center, hospital service corporation, medical service corporation or fraternal benefit society that provides coverage under an individual health insurance policy or contract for positron emission tomography may (1) require total copayments in excess of four hundred dollars for all such in-network imaging services combined annually, or (2) require a copayment in excess of one hundred dollars for each in-network positron emission tomography, provided the physician ordering the radiological service and the physician rendering such service are not the same person or are not participating in the same group practice.

(c) The provisions of subsections (a) and (b) of this section shall not apply to a high deductible health plan as that term is used in subsection (f) of section 38a-493.

(P.A. 06-180, S. 1; 07-54, S. 3; P.A. 10-5, S. 25.)

History: P.A. 07-54 made technical changes in Subsecs. (a) and (b), effective May 22, 2007; P.A. 10-5 replaced reference to Sec. 38a-520 with reference to Sec. 38a-493 in Subsec. (c), effective May 5, 2010.

See Sec. 38a-550 for similar provisions re group policies.

PART III

GROUP HEALTH INSURANCE

Sec. 38a-512. Applicability of statutes to certain major medical expense policies. Any policy providing major medical expense coverage which is written to complement underlying hospital, medical and surgical expense coverage, unless otherwise specifically provided, shall not be required to include the benefits required in the underlying hospital, medical and surgical expense coverage. The provisions of sections 38a-513, 38a-529, 38a-532, 38a-545 and 38a-547 shall not apply to any subscriber contract issued by a health care center.

(P.A. 90-243, S. 96; P.A. 03-199, S. 6.)

History: P.A. 03-199 deleted provision re inapplicability of Sec. 38a-546 to subscriber contracts issued by a health care center.

Sec. 38a-512a. Continuation of coverage. (a)(1) Each insurer, health care center, hospital service corporation, medical service corporation, fraternal benefit society or other entity delivering, issuing for delivery, renewing, amending or continuing a group health insurance policy in this state that provides coverage of the type specified in subdivisions (1), (2), (3), (4), (11) and (12) of section 38a-469 shall provide the option to continue coverage under each of the following circumstances until the individual is eligible for other group insurance, except as provided in subparagraphs (C) and (D) of this subdivision:

(A) Upon layoff, reduction of hours, leave of absence or termination of employment, other than as a result of death of the employee or as a result of such employee’s “gross misconduct” as that term is used in 29 USC 1163(2), continuation of coverage for such employee and such employee’s covered dependents for a period of thirty months after the date of such layoff, reduction of hours, leave of absence or termination of employment, except that if such reduction of hours, leave of absence or termination of employment results from an employee’s eligibility to receive Social Security income, continuation of coverage for such employee and such employee’s covered dependents until midnight of the day preceding such person’s eligibility for benefits under Title XVIII of the Social Security Act;

(B) Upon the death of the employee, continuation of coverage for the covered dependents of such employee for the periods set forth for such event under federal extension requirements established by the Consolidated Omnibus Budget Reconciliation Act of 1985, P.L. 99-272, as amended from time to time;

(C) Regardless of the employee’s or dependent’s eligibility for other group insurance, during an employee’s absence due to illness or injury, continuation of coverage for such employee and such employee’s covered dependents during continuance of such illness or injury or for up to twelve months from the beginning of such absence;

(D) Regardless of an individual’s eligibility for other group insurance, upon termination of the group policy, coverage for covered individuals who were totally disabled on the date of termination shall be continued without premium payment during the continuance of such disability for a period of twelve calendar months following the calendar month in which such policy was terminated, provided claim is submitted for coverage within one year of the termination of such policy;

(E) The coverage of any covered individual shall terminate: (i) As to a child, (I) as set forth in section 38a-512b. If on the date specified for termination of coverage on a child, the child is incapable of self-sustaining employment by reason of mental or physical handicap and chiefly dependent upon the employee for support and maintenance, the coverage on such child shall continue while the plan remains in force and the child remains in such condition, provided proof of such handicap is received by such insurer, center, corporation, society or other entity within thirty-one days of the date on which the child’s coverage would have terminated in the absence of such incapacity. Such insurer, center, corporation, society or other entity may require subsequent proof of the child’s continued incapacity and dependency but not more often than once a year thereafter, or (II) for the periods set forth for such child under federal extension requirements established by the Consolidated Omnibus Budget Reconciliation Act of 1985, P.L. 99-272, as amended from time to time; (ii) as to the employee’s spouse, at the end of the month following the month in which a divorce, court-ordered annulment or legal separation is obtained, whichever is earlier, except that the plan shall provide the option for said spouse to continue coverage for the periods set forth for such events under federal extension requirements established by the Consolidated Omnibus Budget Reconciliation Act of 1985, P.L. 99-272, as amended from time to time; and (iii) as to the employee or dependent who is sixty-five years of age or older, as of midnight of the day preceding such person’s eligibility for benefits under Title XVIII of the federal Social Security Act;

(F) As to any other event listed as a “qualifying event” in 29 USC 1163, as amended from time to time, continuation of coverage for such periods set forth for such event in 29 USC 1162, as amended from time to time, provided such plan may require the individual whose coverage is to be continued to pay up to the percentage of the applicable premium as specified for such event in 29 USC 1162, as amended from time to time.

(2) Any continuation of coverage required by this subsection except subparagraph (D) or (F) of subdivision (1) of this subsection may be subject to the requirement, on the part of the individual whose coverage is to be continued, that such individual contribute that portion of the premium the individual would have been required to contribute had the employee remained an active covered employee, except that the individual may be required to pay up to one hundred two per cent of the entire premium at the group rate if coverage is continued in accordance with subparagraph (A), (B) or (E) of subdivision (1) of this subsection. The employer shall not be legally obligated by section 38a-505 or 38a-546 to pay such premium if not paid timely by the employee.

(b) The plan shall make available to Connecticut residents, in addition to any other conversion privilege available, a conversion privilege under which coverage shall be available immediately upon termination of coverage under the group policy. The terms and benefits offered under the conversion benefits shall be at least equal to the terms and benefits of an individual health insurance policy.

(c) Nothing in this section shall alter or impair existing group policies which have been established pursuant to an agreement which resulted from collective bargaining, and the provisions required by this section shall become effective upon the next regular renewal and completion of such collective bargaining agreement.

(P.A. 11-58, S. 44.)

History: P.A. 11-58 effective July 2, 2011.

See Sec. 31-51o re continuation of coverage in the event of a relocation or closing of a covered establishment.

Sec. 38a-512b. Termination of coverage of children in group policies. Coverage for stepchildren. Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state shall provide that coverage of a child shall terminate no earlier than the policy anniversary date on or after whichever of the following occurs first, the date on which the child: Becomes covered under a group health plan through the dependent’s own employment; or attains the age of twenty-six. Each such policy shall cover a stepchild on the same basis as a biological child.

(P.A. 11-58, S. 38.)

History: P.A. 11-58 effective July 2, 2011.

See Sec. 38a-497 for similar provisions re individual policies.

Sec. 38a-512c. Lifetime limit. (a) No group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state shall include a lifetime limit on the dollar value of benefits for a covered individual, for covered benefits that are essential health benefits, as defined in the Patient Protection and Affordable Care Act, P.L. 111-1448, as amended from time to time, or regulations adopted thereunder.

(b) This section shall not prohibit the inclusion of a lifetime limit on specific covered benefits that are not essential health benefits, provided the lifetime limit for reasonable charges or, when applicable, the allowance agreed upon by a health care provider and an insurer, health care center, hospital service corporation, medical service corporation or fraternal benefit society for charges actually incurred for any specific covered benefit, shall be not less than one million dollars per covered individual.

(P.A. 11-58, S. 43.)

History: P.A. 11-58 effective July 2, 2011.

See Sec. 38a-482c for similar provisions re individual policies.

Sec. 38a-513. Approval of group health insurance policies and certificates. Medicare supplement policies and certificates: Age, gender, previous claim or medical history rating prohibited. Optional life insurance riders. Regulations. Group specified disease policies. (a) No group health insurance policy, as defined by the commissioner, or certificate shall be issued or delivered in this state unless a copy of the form for such policy or certificate has been submitted to and approved by the commissioner under the regulations adopted pursuant to this section. The commissioner shall adopt regulations, in accordance with chapter 54, concerning the provisions, submission and approval of such policies and certificates and establishing a procedure for reviewing such policies and certificates. If the commissioner issues an order disapproving the use of such form, the provisions of section 38a-19 shall apply to such order.

(b) No insurance company, fraternal benefit society, hospital service corporation, medical service corporation, health care center or other entity which delivers or issues for delivery in this state any Medicare supplement policies or certificates shall incorporate in its rates or determinations to grant coverage for Medicare supplement insurance policies or certificates any factors or values based on the age, gender, previous claims history or the medical condition of any person covered by such policy or certificate.

(c) Nothing in this chapter shall preclude the issuance of a group health insurance policy which includes an optional life insurance rider, provided the optional life insurance rider must be filed with and approved by the Insurance Commissioner pursuant to section 38a-430. Any company offering such policies for sale in this state shall be licensed to sell life insurance in this state pursuant to the provisions of section 38a-41.

(d) Not later than January 1, 2009, the commissioner shall adopt regulations, in accordance with chapter 54, to establish minimum standards for benefits in group specified disease policies, certificates, riders, endorsements and benefits.

(P.A. 90-243, S. 97; P.A. 93-390, S. 7, 8; P.A. 96-51, S. 3; P.A. 05-20, S. 6; P.A. 08-181, S. 6; P.A. 11-19, S. 32.)

History: P.A. 93-390 added Subsec. (b) prohibiting the incorporation of factors for age, gender, previous claim or medical condition history, into the insurer’s rate schedule, effective January 1, 1994; P.A. 96-51 added Subsec. (c) to permit optional life insurance riders; P.A. 05-20 made technical changes, amended Subsec. (a) re regulations and amended Subsec. (b) to reference “determinations to grant coverage” and plans “H” to “J”, inclusive, “issued prior to January 1, 2006,” re use of claim history and medical condition, effective July 1, 2005; P.A. 08-181 added Subsec. (d) directing commissioner to adopt regulations to establish minimum benefit standards for group specified disease policies, effective June 12, 2008; P.A. 11-19 amended Subsec. (b) to delete provisions re Medicare supplement plans “H” to “J”.

See Sec. 38a-477a re notification by Insurance Commissioner of required benefits and policy forms.

Sec. 38a-513a. Time limits for coverage determinations. Notice requirements. Except as otherwise provided in this title, each insurer, health care center, hospital service corporation, medical service corporation or other entity delivering, issuing for delivery, renewing, amending or continuing any group health insurance policy in this state providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 shall complete any coverage determination with respect to such policy and notify the insured or the insured’s health care provider of its decision not later than forty-five days after a request for such determination is received by the insurer, health care center, hospital service corporation, medical service corporation or other entity. In the case of a denial of coverage, such entity shall notify the insured and the insured’s health care provider of the reasons for such denial. If the reasons for such denial include that the requested service is not medically necessary or is not a covered benefit under such policy, the entity shall (1) notify the insured that such insured may contact the Office of the Healthcare Advocate if the insured believes the insured has been given erroneous information, and (2) provide to such insured the contact information for said office.

(P.A. 99-284, S. 13; P.A. 10-24, S. 2; P.A. 11-19, S. 24.)

History: P.A. 10-24 made technical changes and added requirement for information re Office of the Healthcare Advocate to be provided to insured for certain denials of coverage, effective January 1, 2011; P.A. 11-19 made technical changes.

See Sec. 38a-483b for similar provisions re individual policies.

Sec. 38a-513b. Coverage and notice re experimental treatments. Appeals. (a) Each group health insurance policy delivered, issued for delivery, renewed, amended or continued in this state shall define the extent to which it provides coverage for experimental treatments.

(b) No such health insurance policy may deny a procedure, treatment or the use of any drug as experimental if such procedure, treatment or drug, for the illness or condition being treated, or for the diagnosis for which it is being prescribed, has successfully completed a phase III clinical trial of the federal Food and Drug Administration.

(c) Any person who has been diagnosed with a condition that creates a life expectancy in that person of less than two years and who has been denied an otherwise covered procedure, treatment or drug on the grounds that it is experimental may request an expedited appeal as provided in section 38a-591e and may appeal a denial thereof to the Insurance Commissioner in accordance with the procedures established in section 38a-591g.

(P.A. 99-284, S. 16, 60; P.A. 11-58, S. 82; P.A. 12-145, S. 44.)

History: P.A. 99-284 effective January 1, 2000; P.A. 11-58 amended Subsec. (c) to replace references to Secs. 38a-226c and 38a-478n with “section 38a-591e” and “section 38a-591g”, respectively, and deleted former Subsec. (d) re appeal of a procedure, treatment or drug denied on grounds that such procedure, treatment or drug is experimental, effective July 1, 2011; P.A. 12-145 amended Subsec. (a) to delete “on or after January 1, 2000”, effective June 15, 2012.

See Sec. 38a-483c for similar provisions re individual policies.

Sec. 38a-513c. Group health insurance policy to contain definition of “medically necessary” or “medical necessity”. (a) No insurer, health care center, hospital service corporation, medical service corporation or other entity delivering, issuing for delivery, renewing, continuing or amending any group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469 in this state shall deliver or issue for delivery in this state any such policy unless such policy contains a definition of “medically necessary” or “medical necessity” as follows: “Medically necessary” or “medical necessity” means health care services that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are: (1) In accordance with generally accepted standards of medical practice; (2) clinically appropriate, in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and (3) not primarily for the convenience of the patient, physician or other health care provider and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease. For the purposes of this subsection, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community or otherwise consistent with the standards set forth in policy issues involving clinical judgment.

(b) The provisions of subsection (a) of this section shall not apply to any insurer, health care center, hospital service corporation, medical service corporation or other entity that has entered into any national settlement agreement until the expiration of any such agreement.

(P.A. 07-75, S. 2; P.A. 11-19, S. 22.)

History: P.A. 07-75 effective January 1, 2008; P.A. 11-19 made technical changes.

See Sec. 38a-482a for similar provisions re individual policies.

Sec. 38a-513d. Insurers prohibited from issuing policy with limited coverage to employer as replacement for a comprehensive health insurance plan. Disclosure required in policy providing limited coverage. Limited coverage defined. (a) No insurer, health care center, hospital service corporation, medical service corporation or other entity delivering, issuing for delivery, renewing, continuing or amending any group health insurance policy in this state on or after January 1, 2008, shall deliver or issue for delivery in this state any policy providing limited coverage to any employer as a replacement for a comprehensive health insurance plan for its employees.

(b) Each group health insurance policy, subscriber contract or certificate of coverage delivered or issued for delivery in this state on or after January 1, 2008, that provides limited coverage, and any marketing material, application for coverage and enrollment material relative to such policy, contract or certificate, shall include the following statement printed in capital letters in not less than twelve-point bold face type and located in a conspicuous manner on such document:

“THIS LIMITED HEALTH BENEFITS PLAN DOES NOT PROVIDE COMPREHENSIVE MEDICAL COVERAGE. IT IS A BASIC OR LIMITED BENEFITS POLICY AND IS NOT INTENDED TO COVER ALL MEDICAL EXPENSES. THIS PLAN IS NOT DESIGNED TO COVER THE COSTS OF SERIOUS OR CHRONIC ILLNESS. IT CONTAINS SPECIFIC DOLLAR LIMITS THAT WILL BE PAID FOR MEDICAL SERVICES WHICH MAY NOT BE EXCEEDED. IF THE COST OF SERVICES EXCEEDS THOSE LIMITS, THE BENEFICIARY AND NOT THE INSURER IS RESPONSIBLE FOR PAYMENT OF THE EXCESS AMOUNTS. THE SPECIFIC DOLLAR LIMITS ARE AS FOLLOWS: (INSURER TO SPECIFY SUCH AMOUNTS).”

(c) For the purposes of this section, “limited coverage” means an insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 that contains an annual maximum benefit of less than one hundred thousand dollars or fixed dollar benefits of less than twenty thousand dollars on any core services. For the purpose of this section, “core services” means medical, surgical and hospital services, including inpatient and outpatient physician, laboratory and imaging services.

(P.A. 07-96, S. 2; P.A. 08-147, S. 12.)

History: P.A. 07-96 effective July 1, 2007; P.A. 08-147 redefined “limited coverage” in Subsec. (c) to specify fixed dollar benefits of less than $20,000 on any core services.

See Sec. 38a-482b for similar provisions re individual policies.

Sec. 38a-513e. Premium payment by employer following employee termination. Exceptions. Right to continuation of coverage following relocation or closing of covered establishment not affected. (a) In the event (1) an employer, as defined in section 31-58, terminates an employee for any reason other than layoff or relocation or closing of a covered establishment, as defined in section 31-51n, or (2) an employee voluntarily terminates employment with an employer, such employer may elect not to pay the premium for such employee and any such employee’s dependents under a group health insurance policy after the date of such employee’s termination. In the event such employer makes such election, any insurer, health care center, hospital or medical service corporation or fraternal benefit society that issues such group health insurance policy shall credit such employer the amount of any premium paid by such employer with respect to such policy for such employee and such employee’s dependents attributable to the period after the date of such employee’s termination, provided the employer notifies the insurer, health care center, hospital or medical service corporation or fraternal benefit society that issued such policy and the terminated employee not later than seventy-two hours after the termination. Upon the issuance or renewal of such policy, such insurer, health care center, hospital or medical service corporation or fraternal benefit society shall provide such employer with relevant information related to such employer’s election, including a notice that it is the employer’s responsibility to remit to the terminated employee such employee’s portion of the credited premium. Any such credit shall be applied to the employer’s next month’s premium. In the event of nonrenewal of such policy, the insurer, health care center, hospital or medical service corporation or fraternal benefit society shall refund such credit to the employer.

(b) Notwithstanding the provisions of subsection (a) of this section, (1) any contractual agreement entered into through collective bargaining that requires the employer to pay the premium for an employee under a group health insurance policy after the date of such employee’s termination shall supersede the provisions of subsection (a) of this section, and (2) no credit shall be available to an employer for any employee’s and employee’s dependents’ coverage for the seventy-two hours immediately following the termination of such employee.

(c) Any right of an employee and his dependents to continuation of coverage following the relocation or closing of a covered establishment, as set forth in section 31-51o, shall not be affected by the provisions of this section.

(P.A. 09-126, S. 1; P.A. 10-5, S. 26.)

History: P.A. 10-5 amended Subsec. (a) to exclude termination of employee due to relocation or closing of a covered establishment from circumstances in which employer may elect not to pay health insurance premium of terminated employee, and added Subsec. (c) re right to continuation of coverage following relocation or closing of a covered establishment not affected by section, effective May 5, 2010.

Sec. 38a-513f. Claims information to be provided to certain employers. Restrictions. Subpoenas. (a) As used in this section:

(1) “Claims paid” means the amounts paid for the covered employees of an employer by an insurer, health care center, hospital service corporation, medical service corporation or other entity as specified in subsection (b) of this section for medical services and supplies and for prescriptions filled, but does not include expenses for stop-loss coverage, reinsurance, enrollee educational programs or other cost containment programs or features, administrative costs or profit.

(2) “Employer” means any town, city, borough, school district, taxing district or fire district employing more than fifty employees.

(3) “Utilization data” means (A) the aggregate number of procedures or services performed for the covered employees of the employer, by practice type and by service category, or (B) the aggregate number of prescriptions filled for the covered employees of the employer, by prescription drug name.

(b) Each insurer, health care center, hospital service corporation, medical service corporation or other entity delivering, issuing for delivery, renewing, amending or continuing in this state any group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11), (12) and (16) of section 38a-469 shall:

(1) Not later than October first, annually, provide to an employer sponsoring such policy, free of charge, the following information for the most recent thirty-six-month period or for the entire period of coverage, whichever is shorter, ending not more than sixty days prior to the date of the request, in a format as set forth in subdivision (3) of this subsection:

(A) Complete and accurate medical, dental and pharmaceutical utilization data, as applicable;

(B) Claims paid by year, aggregated by practice type and by service category, each reported separately for in-network and out-of-network providers, and the total number of claims paid;

(C) Premiums paid by such employer by month; and

(D) The number of insureds by coverage tier, including, but not limited to, single, two-person and family including dependents, by month;

(2) Include in such information specified in subdivision (1) of this subsection only health information that has had identifiers removed, as set forth in 45 CFR 164.514, is not individually identifiable, as defined in 45 CFR 160.103, and is permitted to be disclosed under the Health Insurance Portability and Accountability Act of 1996, P.L. 104-191, as amended from time to time, or regulations adopted thereunder; and

(3) Provide such information (A) in a written report, (B) through an electronic file transmitted by secure electronic mail or a file transfer protocol site, or (C) through a secure web site or web site portal that is accessible by such employer.

(c) Such insurer, health care center, hospital service corporation, medical service corporation or other entity shall not be required to provide such information to the employer more than once in any twelve-month period.

(d) (1) Except as provided in subdivision (2) of this subsection, information provided to an employer pursuant to subsection (b) of this section shall be used by such employer only for the purposes of obtaining competitive quotes for group health insurance or to promote wellness initiatives for the employees of such employer.

(2) Any employer may provide to the Comptroller upon request the information disclosed to such employer pursuant to subsection (b) of this section. The Comptroller shall maintain as confidential any such information.

(e) Any information provided to an employer in accordance with subsection (b) of this section or to the Comptroller in accordance with subdivision (2) of subsection (d) of this section shall not be subject to disclosure under section 1-210. An employee organization, as defined in section 7-467, that is the exclusive bargaining representative of the employees of such employer shall be entitled to receive claim information from such employer in order to fulfill its duties to bargain collectively pursuant to section 7-469.

(f) If a subpoena or other similar demand related to information provided pursuant to subsection (b) of this section is issued in connection with a judicial proceeding to an employer that receives such information, such employer shall immediately notify the insurer, health care center, hospital service corporation, medical service corporation or other entity that provided such information to such employer of such subpoena or demand. Such insurer, health care center, hospital service corporation, medical service corporation or other entity shall have standing to file an application or motion with the court of competent jurisdiction to quash or modify such subpoena. Upon the filing of such application or motion by such insurer, health care center, hospital service corporation, medical service corporation or other entity, the subpoena or similar demand shall be stayed without penalty to the parties, pending a hearing on such application or motion and until the court enters an order sustaining, quashing or modifying such subpoena or demand.

(P.A. 10-163, S. 1; P.A. 11-58, S. 10; P.A. 12-145, S. 18.)

History: P.A. 10-163 effective June 7, 2010; P.A. 11-58 changed “disclose” and “disclosed” to “provide” and “provided”, amended Subsec. (b) to add single service ancillary coverage to types of coverage to which section is applicable, and to require insurers to provide claims data information annually, free of charge, to employer, instead of upon request of employer, in Subdiv. (1), amended Subsec. (d) by designating existing provisions as Subdiv. (1) and adding Subdiv. (2) re provision of information to Comptroller, and made conforming changes, effective July 1, 2011; P.A. 12-145 amended Subsec. (b)(2) and (3) to delete “requested” re information, effective June 15, 2012.

Sec. 38a-513g. Employer submission of plan cost information to Comptroller. (a) For the purposes of this section, “employer” has the same meaning as provided in section 38a-513f.

(b) Not later than October first, annually, each employer that sponsors a fully insured group health insurance policy for its active employees, early retirees and retirees that provides coverage of the type specified in subdivisions (1), (2), (4), (11), (12) and (16) of section 38a-469 shall submit electronically to the Comptroller, in a form prescribed by the Comptroller, the following information: For the two policy years immediately preceding, the percentage increase or decrease in the policy or plan costs, calculated as the total premium costs, inclusive of any premiums or contributions paid by active employees, early retirees and retirees, divided by the total number of active employees, early retirees and retirees covered by such policy.

(P.A. 11-58, S. 9.)

History: P.A. 11-58 effective July 1, 2011.

Sec. 38a-514. (Formerly Sec. 38-174d). Mandatory coverage for the diagnosis and treatment of mental or nervous conditions. Exceptions. Benefits payable re type of provider or facility. State’s claim against proceeds. (a) Except as provided in subsection (j) of this section, each group health insurance policy, providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469, delivered, issued for delivery, renewed, amended or continued in this state shall provide benefits for the diagnosis and treatment of mental or nervous conditions. For the purposes of this section, “mental or nervous conditions” means mental disorders, as defined in the most recent edition of the American Psychiatric Association’s “Diagnostic and Statistical Manual of Mental Disorders”. “Mental or nervous conditions” does not include (1) mental retardation, (2) learning disorders, (3) motor skills disorders, (4) communication disorders, (5) caffeine-related disorders, (6) relational problems, and (7) additional conditions that may be a focus of clinical attention, that are not otherwise defined as mental disorders in the most recent edition of the American Psychiatric Association’s “Diagnostic and Statistical Manual of Mental Disorders”.

(b) No such group policy shall establish any terms, conditions or benefits that place a greater financial burden on an insured for access to diagnosis or treatment of mental or nervous conditions than for diagnosis or treatment of medical, surgical or other physical health conditions.

(c) In the case of benefits payable for the services of a licensed physician, such benefits shall be payable for the same services when such services are lawfully rendered by a psychologist licensed under the provisions of chapter 383 or by such a licensed psychologist in a licensed hospital or clinic.

(d) In the case of benefits payable for the services of a licensed physician or psychologist, such benefits shall be payable for the same services when such services are rendered by:

(1) A clinical social worker who is licensed under the provisions of chapter 383b and who has passed the clinical examination of the American Association of State Social Work Boards and has completed at least two thousand hours of post-master’s social work experience in a nonprofit agency qualifying as a tax-exempt organization under Section 501(c) of the Internal Revenue Code of 1986 or any subsequent corresponding internal revenue code of the United States, as from time to time amended, in a municipal, state or federal agency or in an institution licensed by the Department of Public Health under section 19a-490;

(2) A social worker who was certified as an independent social worker under the provisions of chapter 383b prior to October 1, 1990;

(3) A licensed marital and family therapist who has completed at least two thousand hours of post-master’s marriage and family therapy work experience in a nonprofit agency qualifying as a tax-exempt organization under Section 501(c) of the Internal Revenue Code of 1986 or any subsequent corresponding internal revenue code of the United States, as from time to time amended, in a municipal, state or federal agency or in an institution licensed by the Department of Public Health under section 19a-490;

(4) A marital and family therapist who was certified under the provisions of chapter 383a prior to October 1, 1992;

(5) A licensed alcohol and drug counselor, as defined in section 20-74s, or a certified alcohol and drug counselor, as defined in section 20-74s; or

(6) A licensed professional counselor.

(e) For purposes of this section, the term “covered expenses” means the usual, customary and reasonable charges for treatment deemed necessary under generally accepted medical standards, except that in the case of a managed care plan, as defined in section 38a-478, “covered expenses” means the payments agreed upon in the contract between a managed care organization, as defined in section 38a-478, and a provider, as defined in section 38a-478.

(f) (1) In the case of benefits payable for the services of a licensed physician, such benefits shall be payable for (A) services rendered in a child guidance clinic or residential treatment facility by a person with a master’s degree in social work or by a person with a master’s degree in marriage and family therapy under the supervision of a psychiatrist, physician, licensed marital and family therapist or licensed clinical social worker who is eligible for reimbursement under subdivisions (1) to (4), inclusive, of subsection (d) of this section; (B) services rendered in a residential treatment facility by a licensed or certified alcohol and drug counselor who is eligible for reimbursement under subdivision (5) of subsection (d) of this section; or (C) services rendered in a residential treatment facility by a licensed professional counselor who is eligible for reimbursement under subdivision (6) of subsection (d) of this section.

(2) In the case of benefits payable for the services of a licensed psychologist under subsection (d) of this section, such benefits shall be payable for (A) services rendered in a child guidance clinic or residential treatment facility by a person with a master’s degree in social work or by a person with a master’s degree in marriage and family therapy under the supervision of such licensed psychologist, licensed marital and family therapist or licensed clinical social worker who is eligible for reimbursement under subdivisions (1) to (4), inclusive, of subsection (d) of this section; (B) services rendered in a residential treatment facility by a licensed or certified alcohol and drug counselor who is eligible for reimbursement under subdivision (5) of subsection (d) of this section; or (C) services rendered in a residential treatment facility by a licensed professional counselor who is eligible for reimbursement under subdivision (6) of subsection (d) of this section.

(g) In the case of benefits payable for the service of a licensed physician practicing as a psychiatrist or a licensed psychologist, under subsection (d) of this section, such benefits shall be payable for outpatient services rendered (1) in a nonprofit community mental health center, as defined by the Department of Mental Health and Addiction Services, in a nonprofit licensed adult psychiatric clinic operated by an accredited hospital or in a residential treatment facility; (2) under the supervision of a licensed physician practicing as a psychiatrist, a licensed psychologist, a licensed marital and family therapist, a licensed clinical social worker, a licensed or certified alcohol and drug counselor, or a licensed professional counselor who is eligible for reimbursement under subdivisions (1) to (6), inclusive, of subsection (d) of this section; and (3) within the scope of the license issued to the center or clinic by the Department of Public Health or to the residential treatment facility by the Department of Children and Families.

(h) Except in the case of emergency services or in the case of services for which an individual has been referred by a physician affiliated with a health care center, nothing in this section shall be construed to require a health care center to provide benefits under this section through facilities that are not affiliated with the health care center.

(i) In the case of any person admitted to a state institution or facility administered by the Department of Mental Health and Addiction Services, Department of Public Health, Department of Children and Families or the Department of Developmental Services, the state shall have a lien upon the proceeds of any coverage available to such person or a legally liable relative of such person under the terms of this section, to the extent of the per capita cost of such person’s care. Except in the case of emergency services the provisions of this subsection shall not apply to coverage provided under a managed care plan, as defined in section 38a-478.

(j) A group health insurance policy may exclude the benefits required by this section if such benefits are included in a separate policy issued to the same group by an insurance company, health care center, hospital service corporation, medical service corporation or fraternal benefit society. Such separate policy, which shall include the benefits required by this section and the benefits required by section 38a-533, shall not be required to include any other benefits mandated by this title.

(k) In the case of benefits based upon confinement in a residential treatment facility, such benefits shall be payable in situations in which the insured has a serious mental or nervous condition that substantially impairs the insured’s thoughts, perception of reality, emotional process or judgment or grossly impairs the behavior of the insured, and, upon an assessment of the insured by a physician, psychiatrist, psychologist or clinical social worker, cannot appropriately, safely or effectively be treated in an acute care, partial hospitalization, intensive outpatient or outpatient setting.

(l) The services rendered for which benefits are to be paid for confinement in a residential treatment facility shall be based on an individual treatment plan. For purposes of this section, the term “individual treatment plan” means a treatment plan prescribed by a physician with specific attainable goals and objectives appropriate to both the patient and the treatment modality of the program.

(1971, P.A. 238, S. 1; P.A. 74-34, S. 1, 2; P.A. 75-215, S. 1, 2; 75-286; P.A. 77-604, S. 24, 84; P.A. 79-614; P.A. 82-110; P.A. 83-157; P.A. 84-193, 84-455, S. 2; P.A. 87-275, S. 1; P.A. 89-86, S. 1; P.A. 90-108; 90-193; 90-243, S. 98; P.A. 92-117; P.A. 93-91, S. 1, 2; 93-381, S. 9, 39; P.A. 95-75; 95-116, S. 6; 95-257, S. 11, 12, 21, 58; 95-289, S. 10, 11; P.A. 96-180, S. 122, 166; P.A. 99-284, S. 28, 60; P.A. 00-135, S. 11, 21; P.A. 02-24, S. 7; P.A. 07-73, S. 2(a); P.A. 08-125, S. 1; P.A. 12-145, S. 19, 46.)

History: P.A. 74-34 clarified prohibition by rephrasing statement of applicability and defined “covered expenses”; P.A. 75-215 included renewals in applicability provision and deleted obsolete date reference, raised minimum confinement period from 30 to 60 days in Subsec. (a) and maximum dollar amount of major medical coverage from $500 to $1,000 in Subsec. (b) and redefined “covered expenses” to include reference to usual and customary charges; P.A. 75-286 added Subsec. (c) re services of psychologists; P.A. 77-604 designated definition of “covered expenses” as Subsec. (d); P.A. 79-614 added Subsec. (e) re services of child guidance clinics; P.A. 82-110 inserted new Subsec. (b) re benefits for partial hospitalization sessions, relettering as necessary and added provisions re additional benefits in Subsec. (c), formerly (b); P.A. 83-157 added Subsec. (g) which outlines when benefits shall be payable for the outpatient services of a psychiatrist or psychologist; P.A. 84-193 required that medical benefits contracts issued by health care centers comply with the mental health coverage requirements of this section, except as limited in new Subsec. (h); P.A. 84-455 added Subsec. (i) creating state’s lien upon insurance coverage available to persons receiving care or legally liable relatives; P.A. 87-275 amended Subsec. (c) to increase the maximum for outpatient benefits from $1,000 to $2,000; P.A. 89-86 added Subsec. (j) providing for exclusion of the benefits required by this section in a group contract if such benefits are included in a separate contract issued to the same group which also includes the benefits required by Sec. 38-262b; P.A. 90-108 amended Subsec. (a) to define “residential treatment facility”, added references to “residential treatment facility” to require that mental health benefits must be offered in a setting other than a hospital, added new Subsecs. (l) and (m) specifying that for benefits in a residential treatment center to be payable, the insured must have a serious mental illness, must be hospitalized within a specific time period after confinement in the residential treatment facility and would have been hospitalized if not for the existence of a residential treatment center and that treatment must be based on an individual plan tailored to the patient; P.A. 90-193 inserted new Subsec. (e) re services of certified independent social workers, relettering the remaining Subsecs. and adding references to certified independent social workers in Subsecs. (g) and (h); P.A. 90-243 added a reference to “group health insurance policy” and substituted “policy” for “contract” where occurring; Sec. 38-174d transferred to Sec. 38a-514 in 1991; P.A. 92-117 amended Subsec. (e) to make its provisions apply to the services of a Connecticut certified marriage and family therapist certified prior to October 1, 1992, amended Subsec. (g) to make provisions applicable to the services rendered by a Connecticut certified marriage and family therapist and made technical corrections for statutory consistency throughout section; P.A. 93-91 substituted commissioner and department of children and families for commissioner and department of children and youth services, effective July 1, 1993; P.A. 93-381 replaced department of health services with department of public health and addiction services, effective July 1, 1993; P.A. 95-75 amended Subsec. (g) to authorize payment of benefits for services rendered by a person with a master’s degree in marriage and family therapy under the supervision of a psychiatrist, physician, Connecticut certified marriage and family therapist or a certified independent social worker; P.A. 95-116 replaced references to certified independent social workers with references to licensed clinical social workers; P.A. 95-257 replaced Commissioner and Department of Public Health and Addiction Services with Commissioner and Department of Public Health and replaced Commissioner and Department of Mental Health with Commissioner and Department of Mental Health and Addiction Services, effective July 1, 1995; P.A. 95-289 made technical changes to Subsecs. (e), (g) and (h) concerning changing marital and family therapists from “certified” to “licensed”; P.A. 96-180 amended Subsec. (e)(4) to substitute “marital” for “marriage” in reference to “marital and family therapist”, effective June 3, 1996; P.A. 99-284 rewrote introductory language and designated it as Subsec. (a), added reference to Subdivs. (1), (2), (4), (11) and (12) of Sec. 38a-469, and added coverage for “mental or nervous conditions” and defined term, deleted provisions of Subsecs. (a), (b) and (c), inserted new Subsec. (b) re requirement that no policy place a greater financial burden on an insured for access to diagnosis or treatment of mental or nervous conditions than for other conditions, redesignated former Subsecs. (d) and (e) as (c) and (d), respectively, and added Subdiv. (d)(5) re alcohol and drug counselors, redesignated former Subsec. (f) as (e) and added exception for managed care plans, redesignated former Subsecs. (g) and (h) as (f) and (g), respectively, and added Subdiv. (f)(3) and amended Subdiv. (h)(2) re alcohol and drug counselors, redesignated Subsecs. (i) and (j) as (h) and (i), respectively, and amended Subsec. (i) to add exception re coverage provided under a managed care plan, redesignated former Subsecs. (k), (l) and (m) as (j), (k) and (l), respectively, and made technical changes, effective January 1, 2000; P.A. 00-135 reorganized section and added provisions re licensed professional counselors, effective May 26, 2000; P.A. 02-24 deleted “the” re “post-master’s social work experience” in Subsec. (d)(1) and (3); pursuant to P.A. 07-73 “Department of Mental Retardation” was changed editorially by the Revisors to “Department of Developmental Services”, effective October 1, 2007; P.A. 08-125 amended Subsec. (k) by deleting former provision re hospitalization requirement and limitation to children and adolescents and making conforming and technical changes, effective January 1, 2009; P.A. 12-145 amended Subsec. (a) to delete “on or after January 1, 2000” and amended Subsec. (l) to replace “must” with “shall”, effective June 15, 2012.

See Sec. 38a-538 re conversion and extension rights of group members and re liability of group employers.

See Sec. 38a-488a for similar provisions re individual policies.

Sec. 38a-514a. Biologically-based mental illness. Coverage required. Section 38a-514a is repealed, effective January 1, 2000.

(P.A. 97-99, S. 27; June 18 Sp. Sess. P.A. 97-8, S. 62, 88; P.A. 99-284, S. 59, 60.)

Sec. 38a-514b. Coverage for autism spectrum disorder. (a) As used in this section:

(1) “Applied behavior analysis” means the design, implementation and evaluation of environmental modifications, using behavioral stimuli and consequences, including the use of direct observation, measurement and functional analysis of the relationship between environment and behavior, to produce socially significant improvement in human behavior.

(2) “Autism services provider” means any person, entity or group that provides treatment for autism spectrum disorder pursuant to this section.

(3) “Autism spectrum disorder” means a pervasive developmental disorder set forth in the most recent edition of the American Psychiatric Association’s “Diagnostic and Statistical Manual of Mental Disorders”, including, but not limited to, Autistic Disorder, Rett’s Disorder, Childhood Disintegrative Disorder, Asperger’s Disorder and Pervasive Developmental Disorder Not Otherwise Specified.

(4) “Behavioral therapy” means any interactive behavioral therapies derived from evidence-based research, including, but not limited to, applied behavior analysis, cognitive behavioral therapy, or other therapies supported by empirical evidence of the effective treatment of individuals diagnosed with an autism spectrum disorder, that are: (A) Provided to children less than fifteen years of age; and (B) provided or supervised by (i) a behavior analyst who is certified by the Behavior Analyst Certification Board, (ii) a licensed physician, or (iii) a licensed psychologist. For the purposes of this subdivision, behavioral therapy is “supervised by” such behavior analyst, licensed physician or licensed psychologist when such supervision entails at least one hour of face-to-face supervision of the autism services provider by such behavior analyst, licensed physician or licensed psychologist for each ten hours of behavioral therapy provided by the supervised provider.

(5) “Diagnosis” means the medically necessary assessment, evaluation or testing performed by a licensed physician, licensed psychologist or licensed clinical social worker to determine if an individual has an autism spectrum disorder.

(b) Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 that is delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for the diagnosis and treatment of autism spectrum disorder. For the purposes of this section and section 38a-513c, an autism spectrum disorder shall be considered an illness.

(c) Such policy shall provide coverage for the following treatments, provided such treatments are (1) medically necessary, and (2) identified and ordered by a licensed physician, licensed psychologist or licensed clinical social worker for an insured who is diagnosed with an autism spectrum disorder, in accordance with a treatment plan developed by a licensed physician, licensed psychologist or licensed clinical social worker pursuant to a comprehensive evaluation or reevaluation of the insured:

(A) Behavioral therapy;

(B) Prescription drugs, to the extent prescription drugs are a covered benefit for other diseases and conditions under such policy, prescribed by a licensed physician, licensed physician assistant or advanced practice registered nurse for the treatment of symptoms and comorbidities of autism spectrum disorder;

(C) Direct psychiatric or consultative services provided by a licensed psychiatrist;

(D) Direct psychological or consultative services provided by a licensed psychologist;

(E) Physical therapy provided by a licensed physical therapist;

(F) Speech and language pathology services provided by a licensed speech and language pathologist; and

(G) Occupational therapy provided by a licensed occupational therapist.

(d) Such policy may limit the coverage for behavioral therapy to a yearly benefit of fifty thousand dollars for a child who is less than nine years of age, thirty-five thousand dollars for a child who is at least nine years of age and less than thirteen years of age and twenty-five thousand dollars for a child who is at least thirteen years of age and less than fifteen years of age.

(e) Such policy shall not impose (1) any limits on the number of visits an insured may make to an autism services provider pursuant to a treatment plan on any basis other than a lack of medical necessity, or (2) a coinsurance, copayment, deductible or other out-of-pocket expense for such coverage that places a greater financial burden on an insured for access to the diagnosis and treatment of an autism spectrum disorder than for the diagnosis and treatment of any other medical, surgical or physical health condition under such policy.

(f) (1) Except for treatments and services received by an insured in an inpatient setting, an insurer, health care center, hospital service corporation, medical service corporation or fraternal benefit society may review a treatment plan developed as set forth in subsection (c) of this section for such insured, in accordance with its utilization review requirements, not more than once every six months unless such insured’s licensed physician, licensed psychologist or licensed clinical social worker agrees that a more frequent review is necessary or changes such insured’s treatment plan.

(2) For the purposes of this section, the results of a diagnosis shall be valid for a period of not less than twelve months, unless such insured’s licensed physician, licensed psychologist or licensed clinical social worker determines a shorter period is appropriate or changes the results of such insured’s diagnosis.

(g) Coverage required under this section may be subject to the other general exclusions and limitations of the group health insurance policy, including, but not limited to, coordination of benefits, participating provider requirements, restrictions on services provided by family or household members and case management provisions, except that any utilization review shall be performed in accordance with subsection (f) of this section.

(h) (1) Nothing in this section shall be construed to limit or affect (A) any other covered benefits available to an insured under (i) such group health insurance policy, (ii) section 38a-514, or (iii) section 38a-516a, (B) any obligation to provide services to an individual under an individualized education program pursuant to section 10-76d, or (C) any obligation imposed on a public school by the Individual With Disabilities Education Act, 20 USC 1400 et seq., as amended from time to time.

(2) Nothing in this section shall be construed to require such group health insurance policy to provide reimbursement for special education and related services provided to an insured pursuant to section 10-76d, unless otherwise required by state or federal law.

(P.A. 08-132, S. 2; P.A. 09-115, S. 1; P.A. 11-4, S. 7; P.A. 12-145, S. 20.)

History: P.A. 08-132 effective January 1, 2009; P.A. 09-115 designated existing provisions as Subsec. (b) and amended same by changing coverage from “for physical therapy, speech therapy and occupational therapy services” to “the diagnosis and treatment” of autism spectrum disorders, making conforming changes and adding provision re autism spectrum disorder to be considered an illness, and added Subsec. (a) re definitions, Subsec. (c) re types of treatment and Subsecs. (d) to (h) re limits on coverage, review and exceptions, effective January 1, 2010; P.A. 11-4 amended Subsec. (a)(3) by substituting “pervasive developmental disorder” for “pervasive developmental disorders” and by making a technical change, and amended Subsecs. (a) to (c) by substituting “autism spectrum disorder” for “autism spectrum disorders”, effective May 9, 2011; P.A. 12-145 made a technical change in Subsec. (a)(4), effective June 15, 2012.

See Sec. 38a-488b for provisions re individual policies.

Sec. 38a-515. Continuation of coverage of mentally or physically handicapped children. (a) Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state more than one hundred twenty days after July 1, 1971, that provides that coverage of a dependent child of an employee or other member of the covered group shall terminate upon attainment of the limiting age for dependent children specified in the policy shall also provide in substance that attainment of the limiting age shall not operate to terminate the coverage of the child if at such date the child is and continues thereafter to be both (1) incapable of self-sustaining employment by reason of mental or physical handicap, as certified by the child’s physician on a form provided by the insurer, hospital or medical service corporation, or health care center, and (2) chiefly dependent upon such employee or member for support and maintenance.

(b) Proof of the incapacity and dependency shall be furnished to the insurer, hospital or medical service plan corporation or health care center by the employee or member within thirty-one days of the child’s attainment of the limiting age. The insurer, corporation or center may at any time require proof of the child’s continuing incapacity and dependency. After a period of two years has elapsed following the child’s attainment of the limiting age the insurer, corporation or center may require periodic proof of the child’s continuing incapacity and dependency but in no case more frequently than once every year.

(P.A. 90-243, S. 99; P.A. 11-19, S. 34.)

History: P.A. 11-19 inserted “renewed, amended or continued” and made technical changes in Subsec. (a), effective January 1, 2012.

See Sec. 38a-489 for similar provisions re individual policies.

Sec. 38a-516. Coverage for newly born children. Notification to insurer. (a) Each group health insurance policy delivered, issued for delivery, renewed, amended or continued in this state providing coverage of the type specified in subdivisions (1), (2), (4), (6), (11) and (12) of section 38a-469 for a family member of the insured or subscriber shall, as to such family member’s coverage, also provide that the health insurance benefits applicable for children shall be payable with respect to a newly born child of the insured or subscriber from the moment of birth.

(b) Coverage for such newly born child shall consist of coverage for injury and sickness including necessary care and treatment of medically diagnosed congenital defects and birth abnormalities within the limits of the policy.

(c) If payment of a specific premium fee is required to provide coverage for a child, the policy may require that notification of birth of such newly born child and payment of the required premium or fees shall be furnished to the insurer, hospital service corporation, medical service corporation or health care center not later than sixty-one days after the date of birth in order to continue coverage beyond such sixty-one-day period, provided failure to furnish such notice or pay such premium shall not prejudice any claim originating within such sixty-one-day period.

(P.A. 90-243, S. 100; P.A. 11-19, S. 36; 11-171, S. 4; P.A. 12-145, S. 13.)

History: P.A. 11-19 inserted “delivered, issued for delivery, renewed, amended or continued in this state” in Subsec. (a), made technical changes in Subsec. (c), and deleted former Subsec. (d) re application of section to policies delivered or issued for delivery on or after October 1, 1974, or amended, effective January 1, 2012; P.A. 11-171 inserted “delivered, issued for delivery, renewed, amended or continued in this state” and made a technical change in Subsec. (a), increased time period for insured to notify insurer of birth of child and pay required premium or fee from 31 days to 61 days after birth and made technical changes in Subsec. (c), and deleted former Subsec. (d) re application of section to policies delivered or issued for delivery on or after October 1, 1974, or amended, effective January 1, 2012; P.A. 12-145 made a technical change in Subsec. (a), effective June 15, 2012.

See Sec. 38a-490 for similar provisions re individual policies.

Sec. 38a-516a. Coverage for birth-to-three program. (a) Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for medically necessary early intervention services provided as part of an individualized family service plan pursuant to section 17a-248e. Such policy shall provide coverage for such services provided by qualified personnel, as defined in section 17a-248, for a child from birth until the child’s third birthday.

(b) No such policy shall impose a coinsurance, copayment, deductible or other out-of-pocket expense for such services, except that a high deductible plan, as that term is used in subsection (f) of section 38a-493, shall not be subject to the deductible limits set forth in this section.

(c) Such policy shall provide a maximum benefit of six thousand four hundred dollars per child per year and an aggregate benefit of nineteen thousand two hundred dollars per child over the total three-year period, except that for a child with autism spectrum disorder, as defined in section 38a-514b, who is receiving early intervention services as defined in section 17a-248, the maximum benefit available through early intervention providers shall be fifty thousand dollars per child per year and an aggregate benefit of one hundred fifty thousand dollars per child over the total three-year period as provided for in section 38a-514b. Nothing in this section shall be construed to increase the amount of coverage required for autism spectrum disorder for any child beyond the amounts set forth in section 38a-514b. Any coverage provided for autism spectrum disorder through an individualized family service plan pursuant to section 17a-248e shall be credited toward the coverage amounts required under section 38a-514b.

(d) No payment made under this section shall (1) be applied by the insurer, health care center or plan administrator against or result in a loss of benefits due to any maximum lifetime or annual limits specified in the policy, (2) adversely affect the availability of health insurance to the child, the child’s parent or the child’s family members insured under any such policy, or (3) be a reason for the insurer, health care center or plan administrator to rescind or cancel such policy. Payments made under this section shall not be treated differently than other claim experience for purposes of premium rating.

(P.A. 96-185, S. 7, 16; June 30 Sp. Sess. P.A. 03-3, S. 8; Sept. Sp. Sess. P.A. 09-3, S. 45; P.A. 11-44, S. 148; P.A. 12-44, S. 2.)

History: P.A. 96-185 effective July 1, 1996; June 30 Sp. Sess. P.A. 03-3 deleted provision re coverage for at least $5,000 annually, added Subdivs. (1) and (2) re coverage and benefits to be provided by policy and made technical changes, effective August 20, 2003; Sept. Sp. Sess. P.A. 09-3 amended Subdiv. (2) by increasing per child per year benefit from $3,200 to $6,400 and by increasing 3-year per child aggregate benefit from $9,600 to $19,200, effective October 6, 2009; P.A. 11-44 added provision prohibiting out-of-pocket expenses with exception for high deductible plans, deleted Subdiv. (1) and (2) designators, added exception to provision re maximum benefit for child with autism spectrum disorders, and made technical changes, effective January 1, 2012 (Revisor’s note: References to “autism spectrum disorders” were changed editorially by the Revisors to “autism spectrum disorder” to conform with changes made to Sec. 38a-514b by P.A. 11-4); P.A. 12-44 designated existing provisions as Subsecs. (a) to (d), amended Subsec. (a) to add “amended or continued” re policy and delete “on or after July 1, 1996”, amended Subsec. (d) to add provisions re restrictions on treatment of payment, and made technical changes, effective July 1, 2012.

See Sec. 38a-490a for similar provisions re individual policies.

Sec. 38a-516b. Coverage for hearing aids for children twelve and under. Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for hearing aids for children twelve years of age or younger. Such hearing aids shall be considered durable medical equipment under the policy and the policy may limit the hearing aid benefit to one thousand dollars within a twenty-four-month period.

(P.A. 01-171, S. 16; P.A. 12-145, S. 48.)

History: P.A. 12-145 deleted “on or after October 1, 2001”, effective June 15, 2012.

See Sec. 38a-490b for similar provisions re individual policies.

Sec. 38a-516c. Coverage for craniofacial disorders. Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state on or after October 1, 2003, shall provide coverage for medically necessary orthodontic processes and appliances for the treatment of craniofacial disorders for individuals eighteen years of age or younger if such processes and appliances are prescribed by a craniofacial team recognized by the American Cleft Palate-Craniofacial Association, except that no coverage shall be required for cosmetic surgery.

(P.A. 03-37, S. 2.)

See Sec. 38a-490c for similar provisions re individual policies.

Sec. 38a-516d. Coverage for neuropsychological testing for children diagnosed with cancer. Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state on or after October 1, 2006, shall provide coverage without prior authorization for each child diagnosed with cancer on or after January 1, 2000, for neuropsychological testing ordered by a licensed physician, to assess the extent of any cognitive or developmental delays in such child due to chemotherapy or radiation treatment.

(P.A. 06-131, S. 3.)

See Sec. 38a-492l for similar provisions re individual policies.

Sec. 38a-517. Coverage for services performed by dentist in certain instances. Whenever the term “physician” or “doctor” is used in any group health insurance policy delivered, issued for delivery or renewed in this state on or after October 1, 1975, it shall be deemed to include persons licensed, under the provisions of chapter 379, to engage in the practice of dentistry or dental medicine, when benefits under such policy for care, treatment or services rendered or procedures performed by such person would be payable if rendered or performed by a person licensed under chapter 370.

(P.A. 90-243, S. 101.)

See Sec. 38a-491 for similar provisions re individual policies.

Sec. 38a-517a. Coverage for in-patient, outpatient or one-day dental services in certain instances. (a) Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for general anesthesia, nursing and related hospital services provided in conjunction with in-patient, outpatient or one-day dental services if the following conditions are met:

(1) The anesthesia, nursing and related hospital services are deemed medically necessary by the treating dentist or oral surgeon and the patient’s primary care physician in accordance with the health insurance policy’s requirements for prior authorization of services; and

(2) The patient is either (A) determined by a licensed dentist, in conjunction with a licensed physician who specializes in primary care, to have a dental condition of significant dental complexity that it requires certain dental procedures to be performed in a hospital, or (B) a person who has a developmental disability, as determined by a licensed physician who specializes in primary care, that places the person at serious risk.

(b) The expense of such anesthesia, nursing and related hospital services shall be deemed a medical expense under such health insurance policy and shall not be subject to any limits on dental benefits under such policy.

(P.A. 99-284, S. 41, 60; P.A. 00-135, S. 14, 21; P.A. 03-58, S. 2; P.A. 10-5, S. 27.)

History: P.A. 99-284 effective January 1, 2000; P.A. 00-135 added outpatient or one-day dental services, effective May 26, 2000; P.A. 03-58 divided existing provisions into Subsecs. (a) and (b) and deleted “a child under the age of four who is” from Subsec. (a)(2)(A); P.A. 10-5 made technical changes in Subsec. (a), effective January 1, 2011.

See Sec. 38a-491a for similar provisions re individual policies.

Sec. 38a-517b. Assignment of benefits to a dentist or oral surgeon. No insurer, health care center, hospital service corporation, medical service corporation or other entity delivering, issuing for delivery, renewing, continuing or amending any group health insurance policy in this state providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469, and no dental services plan offering or administering dental services, may refuse to accept or make reimbursement pursuant to an assignment of benefits made to a dentist or oral surgeon by an insured, subscriber or enrollee, provided (1) the dentist or oral surgeon charges the insured, subscriber or enrollee no more for services than the dentist or surgeon charges uninsured patients for the same services, and (2) the dentist or oral surgeon allows the insurer, health care center, corporation or entity to review the records related to the insured, subscriber or enrollee during regular business hours. The insurer, health care center, corporation or entity shall give the dentist or oral surgeon at least forty-eight hours’ notice prior to such review. As used in this section, “assignment of benefits” means the transfer of dental care coverage reimbursement benefits or other rights under an insurance policy, subscription contract or dental services plan by an insured, subscriber or enrollee to a dentist or oral surgeon.

(P.A. 00-33, S. 2, 3; P.A. 11-19, S. 26.)

History: P.A. 00-33 effective July 1, 2000; P.A. 11-19 made technical changes.

See Sec. 38a-491b for similar provisions re individual policies.

Sec. 38a-518. Coverage for accidental ingestion or consumption of controlled drugs. Benefits prescribed. No group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6) and (11) of section 38a-469 shall be delivered, issued for delivery or renewed in this state, or amended to substantially alter or change benefits or coverage, on or after July 1, 1975, unless persons covered under such policy will be eligible for benefits for expenses of emergency medical care arising from accidental ingestion or consumption of a controlled drug, as defined by subdivision (8) of section 21a-240, which are at least equal to the following minimum requirements: (1) In the case of benefits based upon confinement as an inpatient in a hospital, whether or not operated by the state, the period of confinement for which benefits shall be payable shall be at least thirty days in any calendar year. (2) For covered expenses incurred by the insured while other than an inpatient in a hospital, benefits shall be available for such expenses during any calendar year up to a maximum of five hundred dollars. For purposes of this section, the term “covered expenses” means the reasonable charges for treatment deemed necessary under generally accepted medical standards.

(P.A. 90-243, S. 102.)

See Sec. 38a-492 for similar provisions re individual policies.

Sec. 38a-518a. Mandatory coverage for hypodermic needles and syringes. Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469, delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for hypodermic needles or syringes prescribed by a prescribing practitioner, as defined in subdivision (22) of section 20-571, for the purpose of administering medications for medical conditions, provided such medications are covered under the policy. Such benefits shall be subject to any policy provisions that apply to other services covered by such policy.

(P.A. 92-185, S. 5, 6; P.A. 95-264, S. 63; P.A. 11-19, S. 38.)

History: P.A. 95-269 changed “licensed” practitioner to “prescribing” practitioner and referenced the definition section (Revisor’s note: The reference to “prescribing practitioner, as defined in subdivision (21) of ...” was changed editorially by the Revisors to “prescribing practitioner, as defined in subdivision (22) of ...”); P.A. 11-19 inserted “amended or continued” and made technical changes, effective January 1, 2012.

See Sec. 38a-492a for similar provisions re individual policies.

Sec. 38a-518b. Coverage for off-label drug prescriptions. (a) Each group health insurance policy delivered, issued for delivery, renewed, amended or continued in this state, that provides coverage for prescribed drugs approved by the federal Food and Drug Administration for treatment of certain types of cancer or disabling or life-threatening chronic diseases, shall not exclude coverage of any such drug on the basis that such drug has been prescribed for the treatment of a type of cancer or a disabling or life-threatening chronic disease for which the drug has not been approved by the federal Food and Drug Administration, provided the drug is recognized for treatment of the specific type of cancer or a disabling or life-threatening chronic disease for which the drug has been prescribed in one of the following established reference compendia: (1) The U.S. Pharmacopoeia Drug Information Guide for the Health Care Professional (USP DI); (2) The American Medical Association’s Drug Evaluations (AMA DE); or (3) The American Society of Hospital Pharmacists’ American Hospital Formulary Service Drug Information (AHFS-DI).

(b) Nothing in subsection (a) of this section shall be construed to require coverage for any experimental or investigational drugs or any drug which the federal Food and Drug Administration has determined to be contraindicated for treatment of the specific type of cancer or a disabling or life-threatening chronic disease for which the drug has been prescribed.

(c) Except as specified, nothing in this section shall be construed to create, impair, limit or modify authority to provide reimbursement for drugs used in the treatment of any other disease or condition.

(P.A. 94-49, S. 1; P.A. 11-19, S. 40; 11-172, S. 16.)

History: P.A. 11-19 amended Subsec. (a) to add “amended or continued” and make technical changes, effective January 1, 2012; P.A. 11-172 amended Subsec. (a) to add “amended or continued”, add provisions re disabling or life-threatening chronic disease and make technical changes, amended Subsec. (b) to add provision re disabling or life-threatening chronic disease and amended Subsec. (c) to add “Except as specified”, effective January 1, 2012.

See Sec. 38a-492b for similar provisions re individual policies.

Sec. 38a-518c. Coverage for low protein modified food products, amino acid modified preparations and specialized formulas. (a) For purposes of this section:

(1) “Inherited metabolic disease” includes (A) a disease for which newborn screening is required under section 19a-55; and (B) cystic fibrosis.

(2) “Low protein modified food product” means a product formulated to have less than one gram of protein per serving and intended for the dietary treatment of an inherited metabolic disease under the direction of a physician.

(3) “Amino acid modified preparation” means a product intended for the dietary treatment of an inherited metabolic disease under the direction of a physician.

(4) “Specialized formula” means a nutritional formula for children up to age twelve that is exempt from the general requirements for nutritional labeling under the statutory and regulatory guidelines of the federal Food and Drug Administration and is intended for use solely under medical supervision in the dietary management of specific diseases.

(b) Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for amino acid modified preparations and low protein modified food products for the treatment of inherited metabolic diseases if the amino acid modified preparations or low protein modified food products are prescribed for the therapeutic treatment of inherited metabolic diseases and are administered under the direction of a physician.

(c) Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for specialized formulas when such specialized formulas are medically necessary for the treatment of a disease or condition and are administered under the direction of a physician.

(d) Such policy shall provide coverage for such preparations, food products and formulas on the same basis as outpatient prescription drugs.

(P.A. 97-167, S. 2; P.A. 01-101, S. 2; P.A. 04-173, S. 2; P.A. 07-197, S. 2; P.A. 12-145, S. 55.)

History: P.A. 01-101 defined, in new Subsec. (a)(4), and added coverage, in new Subsec. (c), for specialized formula; P.A. 04-173 amended Subsec. (a)(1) and (4) to redefine “inherited metabolic disease” to include cystic fibrosis, and redefine “specialized formula” to include formula for children up to age 8, instead of age 3, and added Subsec. (d) to require coverage on the same basis as for outpatient prescription drugs; P.A. 07-197 amended Subsec. (a)(4) to redefine “specialized formula” to include formula for children up to age 12, instead of age 8, and amended Subsec. (c) to require coverage to be applicable to policies delivered, issued for delivery or renewed in this state on or after October 1, 2007 (Revisor’s note: In Subsecs. (b) and (c), the word “individual” was replaced editorially by the Revisors with the word “group” to correct a codification error and accurately reflect the language of said subsecs., as amended by P.A. 07-197); P.A. 12-145 amended Subsecs. (b) and (c) to delete references to Sec. 38a-469(6), add “amended or continued” re policy and delete 1997 and 2007 date references, effective January 1, 2013.

See Sec. 38a-492c for similar provisions re individual policies.

Sec. 38a-518d. Mandatory coverage for diabetes testing and treatment. (a) Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery or renewed in this state on or after October 1, 1997, shall provide coverage for laboratory and diagnostic tests for all types of diabetes.

(b) Notwithstanding the provisions of section 38a-518a, each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery or renewed in this state on or after October 1, 1997, shall provide medically necessary coverage for the treatment of insulin-dependent diabetes, insulin-using diabetes, gestational diabetes and non-insulin-using diabetes. Such coverage shall include medically necessary equipment, in accordance with the insured person’s treatment plan, drugs and supplies prescribed by a prescribing practitioner, as defined in section 20-571.

(P.A. 97-268, S. 5.)

See Sec. 38a-492d for similar provisions re individual policies.

Sec. 38a-518e. Mandatory coverage for diabetes outpatient self-management training. (a) Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed or continued in this state on or after January 1, 2000, shall provide coverage for outpatient self-management training for the treatment of insulin-dependent diabetes, insulin-using diabetes, gestational diabetes and non-insulin-using diabetes if the training is prescribed by a licensed health care professional who has appropriate state licensing authority to prescribe such training. As used in this section, “outpatient self-management training” includes, but is not limited to, education and medical nutrition therapy. Diabetes self-management training shall be provided by a certified, registered or licensed health care professional trained in the care and management of diabetes and authorized to provide such care within the scope of the professional’s practice.

(b) Benefits shall cover: (1) Initial training visits provided to an individual after the individual is initially diagnosed with diabetes that is medically necessary for the care and management of diabetes, including, but not limited to, counseling in nutrition and the proper use of equipment and supplies for the treatment of diabetes, totaling a maximum of ten hours; (2) training and education that is medically necessary as a result of a subsequent diagnosis by a physician of a significant change in the individual’s symptoms or condition which requires modification of the individual’s program of self-management of diabetes, totaling a maximum of four hours; and (3) training and education that is medically necessary because of the development of new techniques and treatment for diabetes totaling a maximum of four hours.

(c) Benefits provided pursuant to this section shall be subject to the same terms and conditions applicable to all other benefits under such policies.

(P.A. 99-284, S. 44, 60.)

History: P.A. 99-284 effective January 1, 2000.

See Sec. 38a-492e for similar provisions re individual policies.

Sec. 38a-518f. Mandatory coverage for certain prescription drugs removed from formulary. Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state that provides coverage for outpatient prescription drugs shall not deny coverage for an insured for any drug that the insurer removes from its list of covered drugs, or otherwise ceases to provide coverage for, if (1) the insured was using the drug for the treatment of a chronic illness prior to the removal or cessation of coverage, (2) the insured was covered under the policy for the drug prior to the removal or cessation of coverage, and (3) the insured’s attending health care provider states in writing, after the removal or cessation of coverage, that the drug is medically necessary and lists the reasons why the drug is more medically beneficial than the drugs on the list of covered drugs. Such benefits shall be subject to the same terms and conditions applicable to all other benefits under such policies.

(P.A. 99-284, S. 38, 60; P.A. 12-145, S. 57.)

History: P.A. 99-284 effective January 1, 2000; P.A. 12-145 added “amended” re policy and deleted “on or after January 1, 2000”, effective January 1, 2013.

See Sec. 38a-492f for similar provisions re individual policies.

Sec. 38a-518g. Mandatory coverage for prostate cancer screening and treatment. Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for:

(1) Laboratory and diagnostic tests, including, but not limited to, prostate specific antigen (PSA) tests, to screen for prostate cancer for men who are symptomatic or whose biological father or brother has been diagnosed with prostate cancer, and for all men fifty years of age or older; and

(2) The treatment of prostate cancer, provided such treatment is medically necessary and in accordance with guidelines established by the National Comprehensive Cancer Network, the American Cancer Society or the American Society of Clinical Oncology.

(P.A. 99-284, S. 46, 60; P.A. 11-225, S. 2.)

History: P.A. 99-284 effective January 1, 2000; P.A. 11-225 inserted “amended” re policy, designated existing provision re screening coverage as Subdiv. (1), added Subdiv. (2) re treatment coverage, and made technical changes, effective January 1, 2012.

See Sec. 38a-492g for similar provisions re individual policies.

Sec. 38a-518h. Mandatory coverage for certain Lyme disease treatments. Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed or continued in this state on or after January 1, 2000, shall provide coverage for Lyme disease treatment including not less than thirty days of intravenous antibiotic therapy, sixty days of oral antibiotic therapy, or both, and shall provide further treatment if recommended by a board certified rheumatologist, infectious disease specialist or neurologist licensed in accordance with chapter 370 or who is licensed in another state or jurisdiction whose requirements for practicing in such capacity are substantially similar to or higher than those of this state.

(P.A. 99-284, S. 48, 60; June Sp. Sess. P.A. 99-2, S. 3, 72.)

History: P.A. 99-284 effective January 1, 2000; June Sp. Sess. P.A. 99-2 added specialists “licensed in another state or jurisdiction whose requirements for practicing in such capacity are substantially similar to or higher than those of this state”, effective January 1, 2000.

See Sec. 38a-492h for similar provisions re individual policies.

Sec. 38a-518i. Mandatory coverage for pain management. (a) Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (10), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide access to a pain management specialist and coverage for pain treatment ordered by such specialist that may include all means medically necessary to make a diagnosis and develop a treatment plan including the use of necessary medications and procedures.

(b) (1) No such policy that provides coverage for prescription drugs shall require an insured to use, prior to using a brand name prescription drug prescribed by a licensed physician for pain treatment, any alternative brand name prescription drugs or over-the-counter drugs.

(2) Such policy may require an insured to use, prior to using a brand name prescription drug prescribed by a licensed physician for pain treatment, a therapeutically equivalent generic drug.

(c) As used in this section, “pain” means a sensation in which a person experiences severe discomfort, distress or suffering due to provocation of sensory nerves, and “pain management specialist” means a physician who is credentialed by the American Academy of Pain Management or who is a board-certified anesthesiologist, physiatrist, neurologist, oncologist or radiation oncologist with additional training in pain management.

(P.A. 00-216, S. 19, 28; P.A. 11-169, S. 2; P.A. 12-197, S. 21.)

History: P.A. 00-216 effective January 1, 2001; P.A. 11-169 designated existing provisions as Subsecs. (a) and (c), added Subsec. (b) prohibiting insurers from requiring insured to use alternative brand name prescription drugs or over-the-counter drugs prior to using brand name prescription drug prescribed for pain treatment, and made technical changes, effective January 1, 2012; P.A. 12-197 amended Subsec. (c) by adding physiatrist to definition of “pain management specialist”, effective June 15, 2012.

See Sec. 38a-492i re individual health insurance coverage for pain management.

Sec. 38a-518j. Mandatory coverage for ostomy-related supplies. Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state that provides coverage for ostomy surgery shall include coverage, up to two thousand five hundred dollars annually, for medically necessary appliances and supplies relating to an ostomy including, but not limited to, collection devices, irrigation equipment and supplies, skin barriers and skin protectors. As used in this section, “ostomy” includes colostomy, ileostomy and urostomy. Payments under this section shall not be applied to any policy maximums for durable medical equipment. Nothing in this section shall be deemed to decrease policy benefits in excess of the limits in this section.

(P.A. 00-63, S. 2; P.A. 10-5, S. 28; P.A. 11-204, S. 2.)

History: P.A. 10-5 made technical changes, effective January 1, 2011; P.A. 11-204 increased coverage cap from $1,000 to $2,500 annually, effective January 1, 2012.

See Sec. 38a-492j for similar provisions re individual policies.

Sec. 38a-518k. Mandatory coverage for colorectal cancer screening. (a) Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state shall provide coverage for colorectal cancer screening, including, but not limited to, (1) an annual fecal occult blood test, and (2) colonoscopy, flexible sigmoidoscopy or radiologic imaging, in accordance with the recommendations established by the American Cancer Society, based on the ages, family histories and frequencies provided in the recommendations. Except as specified in subsection (b) of this section, benefits under this section shall be subject to the same terms and conditions applicable to all other benefits under such policies.

(b) No such policy shall impose:

(1) A deductible for a procedure that a physician initially undertakes as a screening colonoscopy or a screening sigmoidoscopy; or

(2) A coinsurance, copayment, deductible or other out-of-pocket expense for any additional colonoscopy ordered in a policy year by a physician for an insured. The provisions of this subdivision shall not apply to a high deductible health plan as that term is used in subsection (f) of section 38a-520.

(P.A. 01-171, S. 21; P.A. 11-83, S. 2; P.A. 12-61, S. 2; 12-190, S. 2.)

History: P.A. 11-83 designated existing provisions as Subsec. (a) and amended same to insert reference to American College of Radiology, add exception re Subsec. (b) and make a technical change, and added Subsec. (b) prohibiting out-of-pocket expense for additional colonoscopy ordered by physician in a policy year, effective January 1, 2012; P.A. 12-61 amended Subsec. (a) to delete “American College of Gastroenterology” and “American College of Radiology” re recommendations for colorectal cancer screening, effective January 1, 2013; P.A. 12-190 amended Subsec. (b) to redesignate existing provisions as Subdiv. (2) and make conforming changes therein, and add Subdiv. (1) re deductible for procedure initially undertaken as screening colonoscopy or screening sigmoidoscopy, effective January 1, 2013.

See Sec. 38a-472i for payment amount for professional services component of covered colonoscopy or endoscopy services.

See Sec. 38a-492k for similar provisions re individual policies.

Sec. 38a-518l. Mandatory coverage for certain renewals of prescription eye drops. Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state on or after January 1, 2010, that provides coverage for prescription eye drops, shall not deny coverage for a renewal of prescription eye drops when (1) the renewal is requested by the insured less than thirty days from the later of (A) the date the original prescription was distributed to the insured, or (B) the date the last renewal of such prescription was distributed to the insured, and (2) the prescribing physician indicates on the original prescription that additional quantities are needed and the renewal requested by the insured does not exceed the number of additional quantities needed.

(P.A. 09-136, S. 2.)

History: P.A. 09-136 effective January 1, 2010.

See Sec. 38a-492m for similar provisions re individual policies.

Sec. 38a-518m. Mandatory coverage for certain wound-care supplies. Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 that is delivered, issued for delivery, renewed, amended or continued in this state on or after January 1, 2010, shall provide coverage for wound-care supplies that are medically necessary for the treatment of epidermolysis bullosa and are administered under the direction of a physician.

(P.A. 09-51, S. 2.)

History: P.A. 09-51 effective January 1, 2010.

See Sec. 38a-492n for similar provisions re individual policies.

Sec. 38a-518n. Reserved for future use.

Sec. 38a-518o. Mandatory coverage for bone marrow testing. (a) Subject to the provisions of subsection (b) of this section, each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state shall provide coverage for expenses arising from human leukocyte antigen testing, also referred to as histocompatibility locus antigen testing, for A, B and DR antigens for utilization in bone marrow transplantation.

(b) No such policy shall impose a coinsurance, copayment, deductible or other out-of-pocket expense for such testing in excess of twenty per cent of the cost for such testing per year. The provisions of this subsection shall not apply to a high deductible health plan as that term is used in subsection (f) of section 38a-520.

(c) Such policy shall:

(1) Require that such testing be performed in a facility (A) accredited by the American Society for Histocompatibility and Immunogenetics, or its successor, and (B) certified under the Clinical Laboratory Improvement Act of 1967, 42 USC Section 263a, as amended from time to time; and

(2) Limit coverage to individuals who, at the time of such testing, complete and sign an informed consent form that also authorizes the results of the test to be used for participation in the National Marrow Donor Program.

(d) Such policy may limit such coverage to a lifetime maximum benefit of one testing.

(P.A. 11-88, S. 2.)

History: P.A. 11-88 effective January 1, 2012.

See Sec. 38a-492o for similar provisions re individual policies.

Sec. 38a-519. (Formerly Sec. 38-174j). Offset proviso prohibited in certain policies. Required disclosures for group long-term disability policies. (a) No group health insurance policy that provides disability income protection coverage, delivered, issued for delivery, renewed, amended or continued in this state, and no application, rider or endorsement used in connection therewith shall contain an offset proviso. For the purposes of this subsection, “offset proviso” means any provision of an insurance policy that allows the insurer to reduce its liability for loss or expense from sickness or from bodily injury of the insured by reason of any cost of living increase in other disability benefits that occur after the date a claim commences under such policy.

(b) For each group long-term disability income protection coverage policy delivered, issued for delivery, renewed, amended or continued in this state that contains an offset, the insurer shall disclose to a policyholder in a separate document and in a conspicuous manner in not less than fourteen-point bold face type: (1) That the policy contains an offset; (2) that such offset will function to limit payments to an insured under the policy, taking into account Social Security disability benefits and other benefits the insured may receive; (3) for what other categories of benefits the policy will offset; (4) the percentage of income the policy covers and the maximum dollar limit of the policy, if applicable; and (5) at least one example showing how such offset will operate. Such disclosure shall include a statement that, if an eligible individual wants a policy that does not contain an offset, the individual may contact an insurance agent or company for an individual policy.

(c) The policyholder shall provide to each eligible individual the information and the statement required to be disclosed under subsection (b) of this section.

(P.A. 75-622, S. 1, 3; P.A. 80-416; P.A. 90-243, S. 103; P.A. 10-65, S. 1; P.A. 11-19, S. 12.)

History: P.A. 80-416 prohibited offset provisos in policies in effect on January 1, 1976, and in applications, riders or endorsements after January 1, 1981; P.A. 90-243 made technical corrections for statutory consistency and deleted the references to “contract”; Sec. 38-174j transferred to Sec. 38a-519 in 1991; P.A. 10-65 designated existing provisions as Subsec. (a) and amended same to redefine “offset proviso” and make technical changes and added Subsecs. (b) and (c) re disclosure requirements, effective January 1, 2011; P.A. 11-19 made technical changes in Subsecs. (a) and (b).

Sec. 38a-520. Mandatory coverage for home health care. Deductibles. Exception from deductible limits for medical savings accounts. Archer MSAs and health savings accounts. (a) Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage providing reimbursement for home health care to residents in this state.

(b) For the purposes of this section, “hospital” means an institution which is primarily engaged in providing, by or under the supervision of physicians, to inpatients (1) diagnostic, surgical and therapeutic services for medical diagnosis, treatment and care of injured, disabled or sick persons, or (2) medical rehabilitation services for the rehabilitation of injured, disabled or sick persons, provided “hospital” shall not include a residential care home, nursing home, rest home or alcohol or drug treatment facility, as defined in section 19a-490. For the purposes of this section and section 38a-494, “home health care” means the continued care and treatment of a covered person who is under the care of a physician but only if (A) continued hospitalization would otherwise have been required if home health care was not provided, except in the case of a covered person diagnosed by a physician as terminally ill with a prognosis of six months or less to live, and (B) the plan covering the home health care is established and approved in writing by such physician within seven days following termination of a hospital confinement as a resident inpatient for the same or a related condition for which the covered person was hospitalized, except that in the case of a covered person diagnosed by a physician as terminally ill with a prognosis of six months or less to live, such plan may be so established and approved at any time irrespective of whether such covered person was so confined or, if such covered person was so confined, irrespective of such seven-day period, and (C) such home health care is commenced within seven days following discharge, except in the case of a covered person diagnosed by a physician as terminally ill with a prognosis of six months or less to live.

(c) Home health care shall be provided by a home health agency. The term “home health agency” means an agency or organization which meets each of the following requirements: (1) It is primarily engaged in and is federally certified as a home health agency and duly licensed, if such licensing is required, by the appropriate licensing authority, to provide nursing and other therapeutic services, (2) its policies are established by a professional group associated with such agency or organization, including at least one physician and at least one registered nurse, to govern the services provided, (3) it provides for full-time supervision of such services by a physician or by a registered nurse, (4) it maintains a complete medical record on each patient, and (5) it has an administrator.

(d) Home health care shall consist of, but shall not be limited to, the following: (1) Part-time or intermittent nursing care by a registered nurse or by a licensed practical nurse under the supervision of a registered nurse, if the services of a registered nurse are not available; (2) part-time or intermittent home health aide services, consisting primarily of patient care of a medical or therapeutic nature by other than a registered or licensed practical nurse; (3) physical, occupational or speech therapy; (4) medical supplies, drugs and medicines prescribed by a physician, an advanced practice registered nurse or a physician assistant and laboratory services to the extent such charges would have been covered under the policy or contract if the covered person had remained or had been confined in the hospital; (5) medical social services, as hereinafter defined, provided to or for the benefit of a covered person diagnosed by a physician as terminally ill with a prognosis of six months or less to live. Medical social services are defined to mean services rendered, under the direction of a physician by a qualified social worker holding a master’s degree from an accredited school of social work, including but not limited to (A) assessment of the social, psychological and family problems related to or arising out of such covered person’s illness and treatment; (B) appropriate action and utilization of community resources to assist in resolving such problems; (C) participation in the development of the overall plan of treatment for such covered person.

(e) The policy may contain a limitation on the number of home health care visits for which benefits are payable, but the number of such visits shall not be less than eighty in any calendar year or in any continuous period of twelve months for each person covered under a policy, except in the case of a covered person diagnosed by a physician as terminally ill with a prognosis of six months or less to live, the yearly benefit for medical social services shall not exceed two hundred dollars. Each visit by a representative of a home health agency shall be considered as one home health care visit; four hours of home health aide service shall be considered as one home health care visit.

(f) Home health care benefits may be subject to an annual deductible of not more than fifty dollars for each person covered under a policy and may be subject to a coinsurance provision which provides for coverage of not less than seventy-five per cent of the reasonable charges for such services. Such policy may also contain reasonable limitations and exclusions applicable to home health care coverage. A “high deductible health plan”, as defined in Section 220(c)(2) or Section 223(c)(2) of the Internal Revenue Code of 1986, or any subsequent corresponding internal revenue code of the United States, as from time to time amended, used to establish a “medical savings account” or “Archer MSA” pursuant to Section 220 of said Internal Revenue Code or a “health savings account” pursuant to Section 223 of said Internal Revenue Code shall not be subject to the deductible limits set forth in this subsection.

(g) No policy, except any major medical expense policy as described in subsection (j), shall be required to provide home health care coverage to persons eligible for Medicare.

(h) No insurer, hospital service corporation or health care center shall be required to provide benefits beyond the maximum amount limits contained in its policy.

(i) If a person is eligible for home health care coverage under more than one policy, the home health care benefits shall only be provided by that policy which would have provided the greatest benefits for hospitalization if the person had remained or had been hospitalized.

(j) Each major medical expense policy delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage in accordance with the provisions of this section for home health care to residents in this state whose benefits are no longer provided under Medicare or any applicable individual or group health insurance policy.

(P.A. 90-243, S. 104; P.A. 96-19, S. 7; P.A. 97-112, S. 2; P.A. 03-78, S. 2; P.A. 04-174, S. 7; P.A. 11-19, S. 42, 44.)

History: P.A. 96-19 expanded reference in Subsec. (d) to prescriptions by physicians to include advanced practice registered nurses and physician assistants; P.A. 97-112 replaced “home for the aged” with “residential care home”; P.A. 03-78 amended Subsec. (f) to provide that a high deductible health plan shall not be subject to the deductible limits set forth in said Subsec., effective July 1, 2003; P.A. 04-174 amended Subsec. (f) to add references to “Archer MSA”, “health savings account” and Section 223 of the Internal Revenue Code re “high deductible health plans”, effective June 1, 2004; P.A. 11-19 inserted “amended or continued” and made technical changes in Subsecs. (a) and (j), effective January 1, 2012.

See Sec. 38a-493 for similar provisions re individual policies.

Sec. 38a-521. Home health care by recognized nonmedical systems. Notwithstanding the provisions of section 38a-520, no insurer, health care center or issuer of any service plan contract for hospital or medical expense delivered, issued for delivery or renewed in this state shall be prohibited from providing, at its own discretion, coverage for home health care to persons employing a recognized nonmedical system of health care and treatment.

(P.A. 90-243, S. 105.)

Sec. 38a-522. Medicare supplement policies. Coverage of home health aide service. (a) As used in this section, “Medicare” means the Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965, as amended (Title I, Part I of P.L. 89-97); “Medicare supplement policy” means any group health insurance policy or certificate delivered or issued for delivery to any resident of the state who is eligible for Medicare, except any long-term care policy as defined in section 38a-528.

(b) No insurance company, fraternal benefit society, hospital service corporation, medical service corporation or health care center may deliver or issue for delivery any Medicare supplement policy which has an anticipated loss ratio of less than seventy per cent for any group Medicare supplement policy except that a minimum anticipated loss ratio of seventy-five per cent shall be required for any group Medicare supplement policy defined in Section 1882(g) of Title XVIII of the Social Security Act, 42 USC 1395ss(g), as amended. No such company, society, corporation or center may deliver or issue for delivery any Medicare supplement policy without providing, at the time of solicitation or application for the purchase or sale of such coverage, full and fair disclosure of any coverage supplementing or duplicating Medicare benefits.

(c) Each Medicare supplement policy shall provide coverage for home health aide services for each individual covered under the policy when such services are not paid for by Medicare, provided (1) such services are provided by a certified home health aide employed by a home health care agency licensed pursuant to sections 19a-490 to 19a-503, inclusive, and (2) the individual’s physician has certified, in writing, that such services are medically necessary. The policy shall not be required to provide benefits in excess of five hundred dollars per year for such services. No deductible or coinsurance provisions may be applicable to such benefits. If two or more Medicare supplement policies are issued to the same individual by the same insurer, such coverage for home health aide services shall be included in only one such policy. Notwithstanding the provisions of subsection (g) of this section, the provisions of this subsection shall apply with respect to any Medicare supplement policy delivered, issued for delivery, continued or renewed in this state on or after October 1, 1986.

(d) Whenever a Medicare supplement policy provides coverage for the cost of prescription drugs prescribed after the hospitalization of the insured, outpatient surgical procedures performed on the insured in any licensed hospital shall constitute “hospitalization” for purposes of such prescription drug coverage in such policy.

(e) Notwithstanding the provisions of subsection (g) of this section, each Medicare supplement policy delivered, issued for delivery, continued or renewed in this state on or after October 1, 1988, shall provide benefits, to any woman covered under the policy, for mammographic examinations every year, or more frequently if recommended by the woman’s physician, when such examinations are not paid for by Medicare.

(f) The Insurance Commissioner shall adopt such regulations as he deems necessary in accordance with chapter 54 to carry out the purposes of this section.

(g) The provisions of this section shall apply with respect to any Medicare supplement policy delivered, issued for delivery, continued or renewed in this state on or after October 1, 1987, and prior to the effective date of any regulations adopted pursuant to section 38a-495a.

(P.A. 90-243, S. 106; P.A. 92-60, S. 25; 92-111, S. 3, 4.)

History: P.A. 92-60 in Subsec. (a) made technical corrections for statutory consistency; P.A. 92-111 amended Subsec. (g) to make the provisions of this section applicable to Medicare supplement policy regulations adopted pursuant to Sec. 38a-495a.

See Secs. 38a-495 and 38a-495a re Medicare supplement policies and certificates.

Sec. 38a-523. (Formerly Sec. 38-174p). Group hospital or medical insurance coverage for comprehensive rehabilitation services. (a) For the purposes of this section:

(1) “Comprehensive rehabilitation services” shall consist of the following when provided in a comprehensive rehabilitation facility pursuant to a plan of care approved in writing by a physician licensed in accordance with the provisions of chapter 370 and reviewed by such physician at least every thirty days to determine that continuation of such services are medically necessary for the rehabilitation of the patient: (A) Physician services, physical and occupational therapy, nursing care, psychological and audiological services and speech therapy provided by health care professionals who are licensed by the appropriate state licensing authority to perform such services; (B) social services by a social worker holding a master’s degree from an accredited school of social work; (C) respiratory therapy by a certified respiratory therapist; (D) prescription drugs and medicines which cannot be self-administered; (E) prosthetic and orthotic devices, including the testing, fitting or instruction in the use of such devices; (F) other supplies or services prescribed by a physician for the rehabilitation of a patient and ordinarily furnished by a comprehensive rehabilitation facility.

(2) “Comprehensive rehabilitation facility” means a facility which is: (A) Primarily engaged in providing diagnostic, therapeutic and restorative services through such licensed health care professionals to injured, ill or disabled individuals solely on an outpatient basis and (B) accredited for the provision of such services by the Commission on Accreditation for Rehabilitation Facilities or the Professional Services Board of the American Speech-Language Hearing Association.

(b) Any insurance company, hospital or medical service corporation or health care center authorized to do the business of health insurance in this state shall offer to any individual, partnership, corporation or unincorporated association providing group health insurance coverage of the type specified in subdivisions (1), (2), (4), (6), (11) and (12) of section 38a-469 for its employees or members, a group hospital or medical service plan or contract providing coverage for expenses incurred for comprehensive rehabilitation services under such terms and conditions as are agreed to by the policyholder and the insurer.

(P.A. 82-20, S. 1, 2; P.A. 90-243, S. 107.)

History: P.A. 90-243 added a reference to “health care center” and substituted the reference to “health insurance policy” for “hospital or medical insurance coverage”; Sec. 38-174p transferred to Sec. 38a-523 in 1991.

Sec. 38a-524. Coverage for occupational therapy. (a) For the purposes of this section:

(1) “Occupational therapy” means services provided by a licensed occupational therapist in accordance with a plan of care established and approved in writing by a physician licensed in accordance with the provisions of chapter 370, who has certified that the prescribed care and treatment are not available from sources other than a licensed occupational therapist and which are provided in private practice or in a licensed health care facility. Such plan shall be reviewed and certified at least every two months by such physician.

(2) “Health care facility” means an institution which provides occupational therapy, including, but not limited to, an outpatient clinic, a rehabilitative agency and a skilled or intermediate nursing facility.

(3) “Rehabilitative agency” means an agency which provides an integrated multitreatment program designed to upgrade the function of handicapped disabled individuals by bringing together, as a team, specialized personnel from various allied health fields.

(4) “Partial hospitalization” means a formal program of care provided in a hospital or facility for periods of less than twenty-four hours a day.

(b) Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state that provides coverage for expenses incurred for physical therapy shall provide coverage for occupational therapy provided in private practice or in a health care facility or in a partial hospitalization program on an exchange basis.

(P.A. 90-243, S. 108; P.A. 11-19, S. 46.)

History: P.A. 11-19 inserted “amended or continued” and made technical changes in Subsec. (b), effective January 1, 2012.

See Sec. 38a-496 for similar provisions re individual policies.

Sec. 38a-525. Mandatory coverage for medically necessary ambulance services. Direct payment to ambulance provider. (a) Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for medically necessary ambulance services for persons covered by the policy. The hospital policy shall be primary if a person is covered under more than one policy. The policy shall, as a minimum requirement, cover such services whenever any person covered by the contract is transported when medically necessary by ambulance to a hospital. Such benefits shall be subject to any policy provision which applies to other services covered by such policies. Notwithstanding any other provision of this section, such policies shall not be required to provide benefits in excess of the maximum allowable rate established by the Department of Public Health in accordance with section 19a-177.

(b) (1) Each such group health insurance policy shall provide that any payment by such company, corporation or center for emergency ambulance services under coverage required by this section shall be paid directly to the ambulance provider rendering such service if such provider has complied with the provisions of this subsection and has not received payment for such service from any other source.

(2) Any ambulance provider submitting a bill for direct payment pursuant to this section shall stamp the following statement on the face of each bill: “NOTICE: This bill subject to mandatory assignment pursuant to Connecticut general statutes”.

(3) This subsection shall not apply to any transaction between an ambulance provider and an insurance company, hospital or medical service corporation, health care center or other entity if the parties have entered into a contract providing for direct payment.

(P.A. 90-243, S. 109; P.A. 02-124, S. 2; P.A. 12-145, S. 59.)

History: P.A. 02-124 amended Subsec. (a) to rewrite provisions re policies renewed or amended in this state, substitute “October 1, 2002” for “March 1, 1984”, substitute “medically necessary” for “emergency” re covered ambulance services, delete requirement that person be admitted to hospital as an inpatient in order to obtain coverage, and substitute the maximum allowable rate established by the Department of Public Health for $500 re the maximum required coverage, deleted language in Subsec. (b)(1) re policies delivered, issued for delivery, etc., and amended Subsec. (b)(3) to add “health care center or other entity”; P.A. 12-145 amended Subsec. (a) to add “or continued” re policy and delete “on or after October 1, 2002”, effective January 1, 2013.

See Sec. 38a-498 for similar provisions re individual policies.

Sec. 38a-525a. Preauthorization prohibited for certain 9-1-1 emergency calls. No group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469, delivered, issued for delivery or renewed in this state, on or after October 1, 1996, shall direct or require an enrollee to obtain approval from the insurer or health care center prior to calling a 9-1-1 local prehospital emergency medical service system whenever such enrollee is confronted with a life or limb threatening emergency. For purposes of this section, a “life or limb threatening emergency” means any event which the enrollee believes threatens his life or limb in such a manner that a need for immediate medical care is created to prevent death or serious impairment of health.

(P.A. 96-67, S. 2.)

History: (Revisor’s note: In codifying public act 96-67, an incorrect reference to “of subsection (a)” appearing before the reference to “section 38a-469” was deleted editorially by the Revisors).

See Sec. 38a-498a for similar provisions re individual policies.

Sec. 38a-525b. Mandatory coverage for mobile field hospital. Each group health insurance policy providing coverage of the type specified in subdivisions (1) to (13), inclusive, of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide benefits for isolation care and emergency services provided by the state’s mobile field hospital. Such benefits shall be subject to any policy provisions that apply to other services covered by such policy. The rates paid by group health insurance policies pursuant to this section shall be equal to the rates paid under the Medicaid program, as determined by the Department of Social Services.

(P.A. 05-280, S. 65; P.A. 07-252, S. 71; P.A. 12-145, S. 50.)

History: P.A. 05-280 effective July 1, 2005; P.A. 07-252 substituted “mobile field hospital” for “critical access hospital” and made a technical change, effective July 12, 2007; P.A. 12-145 deleted “on or after July 1, 2005” and made a technical change, effective June 15, 2012.

See Sec. 38a-498b for similar provisions re individual policies.

Sec. 38a-525c. Denial of coverage prohibited for health care services rendered to persons with an elevated blood alcohol content. No group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state shall deny coverage for health care services rendered to treat any injury sustained by any person when such injury is alleged to have occurred or occurs under circumstances in which (1) such person has an elevated blood alcohol content, or (2) such person has sustained such injury while under the influence of intoxicating liquor or any drug or both. For the purposes of this section, “elevated blood alcohol content” means a ratio of alcohol in the blood of such person that is eight-hundredths of one per cent or more of alcohol, by weight.

(P.A. 06-39, S. 2; P.A. 12-145, S. 52.)

History: P.A. 12-145 deleted “on or after October 1, 2006”, effective June 15, 2012.

See Sec. 38a-498c for similar provisions re individual policies.

Sec. 38a-526. Mandatory coverage for services of physician assistants and certain nurses. (a) For the purposes of this section:

(1) “Certified nurse practitioner” means any registered nurse licensed under chapter 378 who has completed a formal educational nurse practitioner program and is certified by the American Nurses’ Association, the National Board of Pediatric Nurse Practitioners and Associates or the Nurses’ Association of the American College of Obstetricians and Gynecologists;

(2) “Certified psychiatric-mental health clinical nurse specialist” means any registered nurse licensed under chapter 378 who has completed a formal educational program as a psychiatric-mental health clinical nurse specialist and is certified by the American Nurses’ Association;

(3) “Certified nurse-midwife” means any individual certified as nurse-midwife pursuant to sections 20-86a to 20-86e, inclusive;

(4) “Physician assistant” means an individual licensed pursuant to section 20-12b.

(b) Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for the services of physician assistants, certified nurse practitioners, certified psychiatric-mental health clinical nurse specialists and certified nurse-midwives if such services are within the individual’s area of professional competence as established by education and licensure or certification and are currently reimbursed when rendered by any other licensed health care provider. Subject to the provisions of chapter 378 and sections 20-86a to 20-86e, inclusive, no insurer, hospital service corporation, medical service corporation or health care center may require signature, referral or employment by any other health care provider as a condition of reimbursement, provided no insurer, hospital service corporation, medical service corporation or health care center may be required to pay for duplicative services actually rendered by both a physician assistant or a certified registered nurse and any other health care provider. The payment of such benefits shall be subject to any policy provisions which apply to other licensed health practitioners providing the same services. Nothing in this section may be construed as permitting (1) any registered nurse to perform or provide services beyond the scope of practice permitted in chapter 378 and sections 20-86a to 20-86e, inclusive, or (2) any physician assistant to perform or provide services beyond the scope of practice permitted in chapter 370.

(P.A. 90-243, S. 110; P.A. 95-74, S. 8, 9; P.A. 11-19, S. 48.)

History: P.A. 95-74 added physician assistants to those whose services must be included in coverage and defined “physician assistant”, effective July 1, 1995 (Revisor’s note: In Subsec. (b) “physicians’ assistants” was changed editorially by the Revisors to “physician assistants” for consistency); P.A. 11-19 inserted “amended or continued” and made technical changes in Subsec. (b), effective January 1, 2012.

See Sec. 38a-499 for similar provisions re individual policies.

Sec. 38a-527. Mandatory coverage for partners, sole proprietors and corporate officers for work-related injuries. (a) Notwithstanding any other provision of the general statutes, no group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (11) and (12) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state may exclude coverage for a bodily injury solely because it was caused by an accident arising out of and in the course of employment to a covered individual who is: (1) A sole proprietor or business partner who is not covered by the provisions of chapter 568 or who accepts the provisions of said chapter 568 pursuant to subdivision (6) of section 31-275; or (2) an employee of a corporation and who is a corporate officer, regardless of any election by such individual to be excluded from coverage under said chapter 568 pursuant to subparagraph (E) of subdivision (5) of section 31-275. The payment of benefits pursuant to this section shall be subject to any policy provisions that apply to a claim not resulting from bodily injury caused by an accident arising out of and in the course of employment.

(b) Whenever any such covered individual who receives benefits for any such injury under such policy has a right of recovery or reimbursement against any person or organization, any carrier that has paid such benefits to or for the individual shall be subrogated to all such rights of recovery or reimbursement to the extent of its payment. Such carrier shall also have a lien on the proceeds of any award or approval of any compromise made by a workers’ compensation commissioner pursuant to the individual’s workers’ compensation claim, in accordance with the provisions of section 38a-470.

(P.A. 90-243, S. 111; P.A. 10-5, S. 29.)

History: P.A. 10-5 made technical changes in Subsec. (a), effective January 1, 2011.

See Sec. 38a-500 for similar provisions re individual policies.

Sec. 38a-528. Long-term care policies. (a)(1) As used in this section, “long-term care policy” means any group health insurance policy or certificate delivered or issued for delivery to any resident of this state on or after July 1, 1986, which is designed to provide, within the terms and conditions of the policy or certificate, benefits on an expense-incurred, indemnity or prepaid basis for necessary care or treatment of an injury, illness or loss of functional capacity provided by a certified or licensed health care provider in a setting other than an acute care hospital, for at least one year after a reasonable elimination period. A long-term care policy shall provide benefits for confinement in a nursing home or confinement in the insured’s own home or both. Any additional benefits provided shall be related to long-term treatment of an injury, illness or loss of functional capacity. “Long-term care policy” shall not include any such policy or certificate which is offered primarily to provide basic Medicare supplement coverage, basic medical-surgical expense coverage, hospital confinement indemnity coverage, major medical expense coverage, disability income protection coverage, accident only coverage, specified accident coverage or limited benefit health coverage.

(2) (A) No insurance company, fraternal benefit society, hospital service corporation, medical service corporation or health care center delivering, issuing for delivery, renewing, continuing or amending any long-term care policy in this state may refuse to accept or make reimbursement pursuant to a claim for benefits submitted by or prepared with the assistance of a managed residential community, as defined in section 19a-693, in accordance with subdivision (7) of subsection (a) of section 19a-694 solely because such claim for benefits was submitted by or prepared with the assistance of a managed residential community.

(B) Each insurance company, fraternal benefit society, hospital service corporation, medical service corporation or health care center delivering, issuing for delivery, renewing, continuing or amending any long-term care policy in this state shall, upon receipt of a written authorization executed by the insured, (i) disclose information to a managed residential community for the purpose of determining such insured’s eligibility for an insurance benefit or payment, and (ii) provide a copy of the initial acceptance or declination of a claim for benefits to the managed residential community at the same time such acceptance or declination is made to the insured.

(b) No insurance company, fraternal benefit society, hospital service corporation, medical service corporation or health care center may deliver or issue for delivery any long-term care policy or certificate which has a loss ratio of less than sixty-five per cent for any group long-term care policy. An issuer shall not use or change premium rates for a long-term care insurance policy or certificate unless the rates have been filed with the Insurance Commissioner. Deviations in rates to reflect policyholder experience shall be permitted, provided each policy form shall meet the loss ratio requirement of this section. Any rate filings or rate revisions shall demonstrate that anticipated claims in relation to premiums when combined with actual experience to date can be expected to comply with the loss ratio requirement of this section. On an annual basis, an insurer shall submit to the Insurance Commissioner an actuarial certification of the insurer’s continuing compliance with the loss ratio requirement of this section. Any rate or rate revision may be disapproved if the commissioner determines that the loss ratio requirement will not be met over the lifetime of the policy form using reasonable assumptions.

(c) No such company, society, corporation or center may deliver or issue for delivery any long-term care policy without providing, at the time of solicitation or application for purchase or sale of such coverage, full and fair disclosure of the benefits and limitations of the policy. The provisions of this subsection shall not be applicable to: (1) Any long-term care policy which is delivered or issued for delivery to one or more employers or labor organizations, or to a trust or to the trustees of a fund established by one or more employers or labor organizations, or a combination thereof, for employees or former employees or a combination thereof or for members or former members or a combination thereof, or the labor organizations; and (2) noncontributory plans.

(d) The Insurance Commissioner shall adopt regulations, in accordance with chapter 54, which address (1) the insured’s right to information prior to his replacing an accident and sickness policy with a long-term care policy, (2) the insured’s right to return a long-term care policy to the insurer, within a specified period of time after delivery, for cancellation, and (3) the insured’s right to accept by his signature, and prior to it becoming effective, any rider or endorsement added to a long-term care policy after the issuance date of such policy, provided (A) any regulations adopted pursuant to subdivisions (1) and (2) of this subsection shall not be applicable to (i) any long-term care policy which is delivered or issued for delivery to one or more employers or labor organizations, or to a trust or to the trustees of a fund established by one or more employers or labor organizations, or a combination thereof or for members or former members or a combination thereof, of the labor organizations, or (ii) noncontributory plans, and (B) any regulations adopted pursuant to subdivision (3) of this subsection shall not be applicable to any group long-term policy. The Insurance Commissioner shall adopt such additional regulations as he deems necessary in accordance with said chapter 54 to carry out the purpose of this section.

(e) The Insurance Commissioner may, upon written request by any such company, society, corporation or center, issue an order to modify or suspend a specific provision of this section or any regulation adopted pursuant thereto with respect to a specific long-term care policy upon a written finding that: (1) The modification or suspension would be in the best interest of the insureds; (2) the purposes to be achieved could not be effectively or efficiently achieved without such modification or suspension; and (3) (A) the modification or suspension is necessary to the development of an innovative and reasonable approach for insuring long-term care, (B) the policy is to be issued to residents of a life care or continuing care retirement community or other residential community for the elderly and the modification or suspension is reasonably related to the special needs or nature of such community, or (C) the modification or suspension is necessary to permit long-term care policies to be sold as part of, or in conjunction with, another insurance product, whenever the commissioner decides not to issue such an order, he shall provide written notice of such decision to the requesting party in a timely manner.

(f) Upon written request by any such company, society, corporation or center, the Insurance Commissioner may issue an order to extend the preexisting condition exclusion period, as established by regulations adopted pursuant to this section, for purposes of specific age group categories in a specific long-term care policy form whenever he makes a written finding that such an extension is in the best interest to the public. Whenever the commissioner decides not to issue such an order, he shall provide written notice of such decision to the requesting party in a timely manner.

(g) The provisions of section 38a-19 shall be applicable to any such requesting party aggrieved by any order or decision of the commissioner made pursuant to subsections (e) and (f) of this section.

(P.A. 90-243, S. 112; P.A. 91-276, S. 2; P.A. 93-239, S. 5; P.A. 94-39, S. 6; P.A. 10-127, S. 3.)

History: P.A. 91-276 substituted 65% for 60% in Subsec. (b) re loss ratio for any individual long-term care policy; P.A. 93-239 added the provision requiring a long-term care policy to provide benefits in the insured’s own home or in both a nursing home and his own home; P.A. 94-39 amended Subsec. (b) by adding provision requiring that issuer not use or change premium rates for a long-term policy or certificate without the filing and approval of the insurance commissioner, that any filing or revision of premium rates must comply with the loss ratio requirement for any group long-term care policy or certificate, that insurer submit annual actuarial certification of its continuing compliance with the loss ratio requirements, authorized disapproval of rate or revision if the commissioner determines that the loss ratio requirement will not be met over the lifetime of the policy form and added references to “policies” and “certificates” for statutory consistency; P.A. 10-127 amended Subsec. (a) by designating existing provisions as Subdiv. (1) and adding Subdiv. (2) re claims for benefits submitted or prepared by and disclosure of information to managed residential communities, effective July 1, 2010.

Sec. 38a-529. Mandatory coverage for services provided by the Veterans’ Home. No group health insurance policy delivered, issued for delivery or renewed in this state on or after October 1, 1988, may exclude coverage for services provided by the Veterans’ Home.

(P.A. 90-243, S. 113; P.A. 04-169, S. 19.)

History: P.A. 04-169 changed the name of the Veterans’ Home and Hospital to the Veterans’ Home, effective June 1, 2004.

See Sec. 38a-502 for similar provisions re individual policies.

Sec. 38a-530. Mandatory coverage for mammography, breast ultrasound and magnetic resonance imaging. Breast density information included in mammography report. (a)(1) Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide benefits for mammographic examinations to any woman covered under the policy that are at least equal to the following minimum requirements: (A) A baseline mammogram for any woman who is thirty-five to thirty-nine years of age, inclusive; and (B) a mammogram every year for any woman who is forty years of age or older.

(2) Such policy shall provide additional benefits for:

(A) Comprehensive ultrasound screening of an entire breast or breasts if a mammogram demonstrates heterogeneous or dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology or if a woman is believed to be at increased risk for breast cancer due to family history or prior personal history of breast cancer, positive genetic testing or other indications as determined by a woman’s physician or advanced practice registered nurse; and

(B) Magnetic resonance imaging of an entire breast or breasts in accordance with guidelines established by the American Cancer Society.

(b) Benefits under this section shall be subject to any policy provisions that apply to other services covered by such policy.

(c) Each mammography report provided to a patient shall include information about breast density, based on the Breast Imaging Reporting and Data System established by the American College of Radiology. Where applicable, such report shall include the following notice: “If your mammogram demonstrates that you have dense breast tissue, which could hide small abnormalities, you might benefit from supplementary screening tests, which can include a breast ultrasound screening or a breast MRI examination, or both, depending on your individual risk factors. A report of your mammography results, which contains information about your breast density, has been sent to your physician’s office and you should contact your physician if you have any questions or concerns about this report.”.

(P.A. 90-243, S. 114; P.A. 01-171, S. 23; P.A. 05-69, S. 2; P.A. 06-38, S. 2; P.A. 09-41, S. 2; P.A. 11-67, S. 2; 11-171, S. 2; P.A. 12-150, S. 2.)

History: P.A. 01-171 added “amended or continued” re policies in this state, substituted “October 1, 2001,” for “October 1, 1988,” re policy date, and consolidated Subdivs. (2) and (3) to provide annual coverage for any woman who is forty or over rather than coverage every two years for women 40 to 49 and annually thereafter; P.A. 05-69 added Subsec. designators (a) and (b), amended Subsec. (a) to require comprehensive ultrasound screening for certain women if recommended by a physician, and made technical changes in Subsec. (b); P.A. 06-38 amended Subsec. (a) to require policy to provide additional benefits for comprehensive ultrasound screening of an entire breast or breasts if mammogram demonstrates heterogeneous or dense breast tissue based on the BIRAD System or if a woman is believed to be at increased risk for breast cancer due to family history or prior personal history of breast cancer, positive genetic testing or other indications determined by a physician or advanced practice registered nurse, eliminating reference to screening recommended by a physician for a woman classified as a category 2, 3, 4 or 5 under such system; P.A. 09-41 added Subsec. (c) re breast density information required to be provided to a patient and notice where applicable; P.A. 11-67 amended Subsec. (a) to add mandatory coverage for magnetic resonance imaging if a mammogram demonstrates heterogeneous or dense breast tissue or if a woman is believed to be at increased risk for breast cancer due to family or prior personal history, and to make technical changes, effective January 1, 2012; P.A. 11-171 amended Subsec. (a) to add mandatory coverage for magnetic resonance imaging in accordance with guidelines established by the American Cancer Society or the American College of Radiology, and to make technical changes, effective January 1, 2012; P.A. 12-150 amended Subsec. (a)(2) to delete “and magnetic resonance imaging” in Subpara. (A) and add “of an entire breast or breasts” and delete reference to American College of Radiology in Subpara. (B), amended Subsec. (c) to delete “On and after October 1, 2009”, and made technical changes, effective June 15, 2012.

See Sec. 38a-503 for similar provisions re individual policies.

Sec. 38a-530a. Mandatory coverage for breast cancer survivors. (a) No group health insurance plan, as defined in subdivision (1) of subsection (a) of section 38a-476, or insurance arrangement, as defined in subdivision (2) of subsection (a) of section 38a-476, may refuse to cover a group health insurance applicant due to breast cancer if such applicant has remained free from breast cancer for at least five years prior to the applicant’s request for group health insurance coverage. The group health insurance carrier may require that the applicant submit to a physical examination.

(b) The provisions of this section shall apply to every health insurance plan or insurance arrangement issued, renewed or continued in this state on or after October 1, 1996. For purposes of this section, the date a plan or arrangement is continued shall be the anniversary date of the issuance of the plan or arrangement.

(P.A. 96-177, S. 3.)

See Sec. 38a-476(a) re breast cancer and preexisting conditions clauses.

See Sec. 38a-503a for similar provisions re individual policies.

Sec. 38a-530b. Carriers to permit direct access to obstetrician-gynecologist. (a) As used in this section, “carrier” means each insurer, health care center, hospital service corporation, medical service corporation or other entity delivering, issuing for delivery, renewing, amending or continuing any group health insurance policy in this state providing coverage of the type specified in subdivisions (1), (2), (4), (6), (11) and (12) of section 38a-469.

(b) Each carrier shall permit a female enrollee direct access to a participating in-network obstetrician-gynecologist for any gynecological examination or care related to pregnancy and shall allow direct access to a participating in-network obstetrician-gynecologist for primary and preventive obstetric and gynecologic services required as a result of any gynecological examination or as a result of a gynecological condition. Such obstetric and gynecologic services include, but are not limited to, pap smear tests. The plan may require the participating in-network obstetrician-gynecologist to discuss such services and any treatment plan with the female enrollee’s primary care provider. Nothing in this section shall preclude access to an in-network nurse-midwife as licensed pursuant to sections 20-86c and 20-86g and in-network advanced practice registered nurses, as licensed pursuant to sections 20-93 and 20-94a for obstetrical and gynecological services within their scope of practice.

(c) Each carrier may allow a female enrollee to designate either a participating, in-network obstetrician-gynecologist or any other in-network physician designated by the carrier as a primary care provider, or both, and may offer the same choice to all female enrollees.

(P.A. 95-199, S. 2; P.A. 96-227, S. 15; P.A. 01-171, S. 19; P.A. 10-32, S. 121; P.A. 11-19, S. 50.)

History: P.A. 96-227 amended Subsec. (a) to include Subdiv. (12) in its citation to Sec. 38a-469; P.A. 01-171 amended Subsec. (b) to provide that “such obstetric and gynecologic services include, but are not limited to, pap smear tests”; P.A. 10-32 made a technical change in Subsec. (b), effective May 10, 2010; P.A. 11-19 inserted “or continuing” and made technical changes in Subsec. (a), effective January 1, 2012.

See Sec. 38a-503b for similar provisions re individual policies.

Sec. 38a-530c. Mandatory coverage for maternity care. Notice required. (a) As used in this section, “carrier” means each insurer, health care center, hospital service corporation, medical service corporation or other entity delivering, issuing for delivery, renewing, amending or continuing any group health insurance policy in this state providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469.

(b) Each group insurance carrier that offers maternity benefits shall provide coverage of a minimum of forty-eight hours of inpatient care for a mother and her newborn infant following a vaginal delivery and a minimum of ninety-six hours of inpatient care for a mother and her newborn infant following a caesarean delivery. The time periods shall commence at the time of delivery.

(c) Any decision to shorten the length of inpatient stay to less than that provided under subsection (b) of this section shall be made by the attending health care providers after conferring with the mother.

(d) If a mother and newborn are discharged pursuant to subsection (c) of this section, prior to the inpatient length of stay provided under subsection (b) of this section, coverage shall be provided for a follow-up visit within forty-eight hours of discharge and an additional follow-up visit within seven days of discharge. Such follow-up services shall include, but not be limited to, physical assessment of the newborn, parent education, assistance and training in breast or bottle feeding, assessment of the home support system and the performance of any medically necessary and appropriate clinical tests. Such services shall be consistent with protocols and guidelines developed by attending providers or by national pediatric, obstetric and nursing professional organizations for these services and shall be provided by qualified health care personnel trained in postpartum maternal and newborn pediatric care.

(e) Each group insurance carrier shall provide notice to policyholders regarding the coverage required under this section. The notice shall be in writing and shall be transmitted at the earliest of either the next mailing to the policyholder, the yearly summary of benefits sent to the policyholder or January 1, 1997.

(P.A. 96-177, S. 2, 6; P.A. 11-19, S. 52.)

History: P.A. 96-177 effective May 24, 1996; P.A. 11-19 inserted “or continuing” and made technical changes in Subsec. (a), effective January 1, 2012.

See Sec. 38a-503c for similar provisions re individual policies.

Sec. 38a-530d. Mandatory coverage for mastectomy care. Termination of provider contract prohibited. (a) Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (10), (11) and (12) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state shall provide coverage for at least forty-eight hours of inpatient care following a mastectomy or lymph node dissection, and shall provide coverage for a longer period of inpatient care if such care is recommended by the patient’s treating physician after conferring with the patient. No such insurance policy may require mastectomy surgery or lymph node dissection to be performed on an outpatient basis. Outpatient surgery or shorter inpatient care is allowable under this section if the patient’s treating physician recommends such outpatient surgery or shorter inpatient care after conferring with the patient.

(b) No group health insurance carrier may terminate the services of, require additional documentation from, require additional utilization review, reduce payments or otherwise penalize or provide financial disincentives to any attending health care provider on the basis that the provider orders care consistent with the provisions of this section.

(P.A. 97-198, S. 2, 5; P.A. 11-19, S. 9.)

History: P.A. 97-198 effective July 1, 1997; P.A. 11-19 made a technical change in Subsec. (a).

See Sec. 38a-503d for similar provisions re individual policies.

Sec. 38a-530e. Mandatory coverage for prescription contraceptives. (a) Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state that provides coverage for outpatient prescription drugs approved by the federal Food and Drug Administration shall not exclude coverage for prescription contraceptive methods approved by the federal Food and Drug Administration.

(b) (1) Notwithstanding any other provision of this section, any insurance company, hospital or medical service corporation, or health care center may issue to a religious employer a group health insurance policy that excludes coverage for prescription contraceptive methods which are contrary to the religious employer’s bona fide religious tenets.

(2) Notwithstanding any other provision of this section, upon the written request of an individual who states in writing that prescription contraceptive methods are contrary to such individual’s religious or moral beliefs, any insurance company, hospital or medical service corporation, or health care center may issue to or on behalf of the individual a policy or rider thereto that excludes coverage for prescription contraceptive methods.

(c) Any health insurance policy issued pursuant to subsection (b) of this section shall provide written notice to each insured or prospective insured that prescription contraceptive methods are excluded from coverage pursuant to said subsection. Such notice shall appear, in not less than ten-point type, in the policy, application and sales brochure for such policy.

(d) Nothing in this section shall be construed as authorizing a group health insurance policy to exclude coverage for prescription drugs ordered by a health care provider with prescriptive authority for reasons other than contraceptive purposes.

(e) Notwithstanding any other provision of this section, any insurance company, hospital or medical service corporation, or health care center which is owned, operated or substantially controlled by a religious organization which has religious or moral tenets which conflict with the requirements of this section may provide for the coverage of prescription contraceptive methods as required under this section through another such entity offering a limited benefit plan. The cost, terms and availability of such coverage shall not differ from the cost, terms and availability of other prescription coverage offered to the insured.

(f) As used in this section, “religious employer” means an employer that is a “qualified church-controlled organization” as defined in 26 USC 3121 or a church-affiliated organization.

(P.A. 99-79, S. 2; P.A. 11-19, S. 54.)

History: P.A. 11-19 inserted “amended” and made a technical change in Subsec. (a), effective January 1, 2012.

See Sec. 38a-503e for similar provisions re individual policies.

Sec. 38a-531. (Formerly Sec. 38-174hh). Mandatory coverage for employees of certain employers. Approval of policy forms. (a) For purposes of this section: (1) “Employer” means any person, firm, corporation, limited liability company, partnership or association engaged in business who has employees in this state; (2) “employee” means any person engaged in service to an employer in a business of an employer; and (3) “continued” or “continuance date” means the anniversary date of the issuance of a policy after which the policy remains in effect until cancelled.

(b) Notwithstanding any other provisions of the general statutes, each group health insurance policy providing coverage of the type specified in subdivisions (1), (2) and (4) of section 38a-469 delivered, issued for delivery, renewed or continued in any other state offered by an employer, shall provide to covered employees of such employer employed in this state whenever, on the initial effective date of such policy or any renewal or continuance date thereafter, fifty-one per cent or more of the covered employees of such employer are employed in this state, coverage that meets the requirements of this title. The forms of such policies shall be submitted to the Insurance Commissioner for approval.

(P.A. 88-110; P.A. 89-83; P.A. 90-20, S. 1; 90-243, S. 115; P.A. 92-60, S. 26; P.A. 95-79, S. 142, 189; P.A. 03-119, S. 2.)

History: P.A. 89-83 required coverage for mammography as set forth in Sec. 38-174gg when 51% or more of the employees covered under a policy provided by an employer are employed in this state; P.A. 90-20 amended Subsec. (a) to include a definition of “continued” and to amend Subsec. (b) to require mandatory benefits for preventive pediatric care policies when 51% or more of covered employees are employed in this state; P.A. 90-243 made technical changes for statutory consistency; Sec. 38-174hh transferred to Sec. 38a-531 in 1991; P.A. 92-60 amended Subsec. (b) to replace the “individual health insurance” section references with “group health insurance” section references for statutory consistency; P.A. 95-79 amended Subsec. (a) to redefine “employer” to include a limited liability company, effective May 31, 1995; P.A. 03-119 made a technical change in Subsec. (a) and amended Subsec. (b) to replace requirement that coverage meet the requirements of certain enumerated sections with requirement that coverage meet the requirements of this title, delete references to certain dates and make technical changes.

Sec. 38a-532. (Formerly Sec. 38-262a). Assignment of incidents of ownership under group life, health or accident policy. Any person who is insured under any policy of group health insurance is permitted to make an assignment of all or any part of his incidents of ownership in such insurance, including, without limitation, any right to designate a beneficiary or beneficiaries thereunder and any right to have an individual policy issued upon termination either of employment or of said policy of group health insurance, if applicable, provided that the insurer or group policyholder may prohibit or restrict such assignment by appropriate policy provisions. Such an assignment, subject to the terms of the policy or agreement between the group policyholder and the insurer, is valid for the purpose of vesting in the assignee, in accordance with any provisions included therein as to the time at which it is to be effective, all rights, benefits and incidents of ownership conferred under the policy and shall entitle the insurer to deal with the assignee as the owner of such rights, benefits and incidents of ownership, provided the insurer shall not be affected by any assignment until he has received written notice thereof.

(1969, P.A. 205, S. 1; P.A. 73-97; P.A. 90-243, S. 116.)

History: P.A. 73-97 made provisions applicable to group accident and group accident and health insurance, clarified assignment rights and deleted obsolete reference to May 21, 1969; Sec. 38-153a transferred to Sec. 38-262a in 1975; P.A. 90-243 made technical changes for statutory consistency and deleted references to “group accident insurance” and “life insurance”; Sec. 38-262a transferred to Sec. 38a-532 in 1991.

Annotation to former section 38-153a:

Conservatrix, prohibited from assigning group life policy, when. 30 CS 327.

Sec. 38a-533. (Formerly Sec. 38-262b). Mandatory coverage for the treatment of medical complications of alcoholism. (a) Except as provided in subsection (c) of this section, each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 shall provide coverage for expenses incurred in connection with medical complications of alcoholism pursuant to diagnosis or recommendation by a physician licensed pursuant to the provisions of chapter 370. As used in this section, “medical complications of alcoholism” means such diseases as cirrhosis of the liver, gastrointestinal bleeding, pneumonia, and delirium tremens.

(b) Medical complications of alcoholism shall be recognized to the extent specified in the contract for confinement for any other disease.

(c) A group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 may exclude the benefits required by this section if such benefits are included in a separate policy issued to the same group by an insurance company, health care center, hospital service corporation, medical service corporation or fraternal benefit society. Such separate policy, which shall include the benefits required by this section, shall not be required to include any other benefits mandated by this title.

(d) The provisions of this section shall apply to any group health insurance policy delivered or issued for delivery, renewed or continued in this state on and after January 1, 2000, and to any group health insurance policy which is thereafter amended to substantially alter or change benefits or coverages.

(P.A. 74-162, S. 1–6; P.A. 89-86, S. 2; P.A. 90-102, S. 1; 90-243, S. 117; P.A. 99-284, S. 29, 60.)

History: P.A. 89-86 inserted new Subsec. (e) providing for exclusion of the benefits required by this section in a group contract if such benefits are included in a separate contract issued to the same group which also includes the benefits required by Sec. 38-174d and relettered former Subsec. accordingly; P.A. 90-102 added Subdivs. (3) and (4) defining “substance abuse” and “continued”, replaced the references to “alcoholism” with “substance abuse” and amended Subsec. (f) to make the provisions of this section apply to policies renewed or continued on or after October 1, 1990; P.A. 90-243 substituted “health insurance policy” for “hospital or medical expense insurance policy and group hospital or medical service plan contract on an expense incurred basis”, inserted the reference “health” and deleted the reference “group subscriber contract”; Sec. 38-262b transferred to Sec. 38a-533 in 1991; P.A. 99-284 deleted former Subsec. (a) re definitions, redesignated former Subsec. (b) as (a) and inserted definition of “medical complications of alcoholism”, redesignated former Subsec. (c) as (b) and deleted reference to confinement for treatment of substance abuse or medical complications of alcoholism in a hospital, deleted former Subsec. (d) re confinement for treatment of substance abuse, redesignated former Subsecs. (e) and (f) as (c) and (d), respectively, and amended Subsecs. (a) and (c) to delete reference to Sec. 38a-469(6), amended Subsec. (c) to delete reference to benefits required by Sec. 38a-514, and amended Subsec. (d) to substitute “January 1, 2000” for “October 1, 1990”, and made technical changes, effective January 1, 2000.

Sec. 38a-534. Coverage for services performed by chiropractors. Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6) and (11) of section 38a-469, delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for services rendered by a chiropractor licensed under chapter 372 to the same extent coverage is provided for services rendered by a physician, if such chiropractic services (1) treat a condition covered under such policy, and (2) are within those services a chiropractor is licensed to perform.

(P.A. 90-243, S. 177; P.A. 11-19, S. 56.)

History: P.A. 11-19 inserted “amended or continued” and made technical changes, effective January 1, 2012.

See Sec. 38a-507 for similar provisions re individual policies.

Sec. 38a-535. Mandatory coverage for preventive pediatric care and blood lead screening and risk assessment. (a) For purposes of this section, “preventive pediatric care” means the periodic review of a child’s physical and emotional health from birth through six years of age by or under the supervision of a physician. Such review shall include a medical history, complete physical examination, developmental assessment, anticipatory guidance, appropriate immunizations and laboratory tests in keeping with prevailing medical standards.

(b) Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (11) and (12) of section 38a-469 delivered, issued for delivery or renewed on or after October 1, 1989, or continued as defined in section 38a-531, on or after October 1, 1990, shall provide benefits for preventive pediatric care for any child covered by the policy or contract at approximately the following age intervals: Every two months from birth to six months of age, every three months from nine to eighteen months of age and annually from two through six years of age. Any such policy may provide that services rendered during a periodic review shall be covered to the extent that such services are provided by or under the supervision of a single physician during the course of one visit. On and after January 1, 2009, each such policy shall also provide coverage for blood lead screening and risk assessments ordered by a primary care provider pursuant to section 19a-111g. Such benefits shall be subject to any policy provisions which apply to other services covered by such policy.

(P.A. 89-101; P.A. 90-20, S. 2; 90-243, S. 178; P.A. 91-407, S. 6, 42; June Sp. Sess. P.A. 07-2, S. 52.)

History: P.A. 90-20 made technical changes in Subsec. (a) and amended Subsec. (b) to require mandatory benefits for preventive pediatric care policies which are continued on or after October 1, 1990; P.A. 90-243 deleted the references to “group hospital or medical expense insurance policy” and “group hospital or medical service plan contract” and inserted “health insurance policy”, made technical corrections for statutory consistency and deleted the reference to “contract”; P.A. 91-407 amended Subsec. (b) by changing “two to six years” to “two through six years”; June Sp. Sess. P.A. 07-2 amended Subsec. (b) to mandate coverage for blood lead screening and risk assessments ordered by a primary care provider under Sec. 19a-111g and to make a technical change, effective January 1, 2009.

Sec. 38a-535a. Notification of individual coverage and benefits of a noncustodial parent to a custodial parent, when. Regulations. Section 38a-535a is repealed, effective July 1, 1995.

(May Sp. Sess. P.A. 94-5, S. 5, 30; P.A. 95-305, S. 5, 6.)

Sec. 38a-536. Mandatory coverage for infertility diagnosis and treatment. Limitations. (a) Subject to the limitations set forth in subsection (b) of this section and except as provided in subsection (c) of this section, each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state on or after October 1, 2005, shall provide coverage for the medically necessary expenses of the diagnosis and treatment of infertility, including, but not limited to, ovulation induction, intrauterine insemination, in-vitro fertilization, uterine embryo lavage, embryo transfer, gamete intra-fallopian transfer, zygote intra-fallopian transfer and low tubal ovum transfer. For purposes of this section, “infertility” means the condition of a presumably healthy individual who is unable to conceive or produce conception or sustain a successful pregnancy during a one-year period.

(b) Such policy may:

(1) Limit such coverage to an individual until the date of such individual’s fortieth birthday;

(2) Limit such coverage for ovulation induction to a lifetime maximum benefit of four cycles;

(3) Limit such coverage for intrauterine insemination to a lifetime maximum benefit of three cycles;

(4) Limit lifetime benefits to a maximum of two cycles, with not more than two embryo implantations per cycle, for in-vitro fertilization, gamete intra-fallopian transfer, zygote intra-fallopian transfer or low tubal ovum transfer, provided each such fertilization or transfer shall be credited toward such maximum as one cycle;

(5) Limit coverage for in-vitro fertilization, gamete intra-fallopian transfer, zygote intra-fallopian transfer and low tubal ovum transfer to those individuals who have been unable to conceive or produce conception or sustain a successful pregnancy through less expensive and medically viable infertility treatment or procedures covered under such policy. Nothing in this subdivision shall be construed to deny the coverage required by this section to any individual who foregoes a particular infertility treatment or procedure if the individual’s physician determines that such treatment or procedure is likely to be unsuccessful;

(6) Require that covered infertility treatment or procedures be performed at facilities that conform to the standards and guidelines developed by the American Society of Reproductive Medicine or the Society of Reproductive Endocrinology and Infertility;

(7) Limit coverage to individuals who have maintained coverage under such policy for at least twelve months; and

(8) Require disclosure by the individual seeking such coverage to such individual’s existing health insurance carrier of any previous infertility treatment or procedures for which such individual received coverage under a different health insurance policy. Such disclosure shall be made on a form and in the manner prescribed by the Insurance Commissioner.

(c) (1) Any insurance company, hospital or medical service corporation, or health care center may issue to a religious employer a group health insurance policy that excludes coverage for methods of diagnosis and treatment of infertility that are contrary to the religious employer’s bona fide religious tenets.

(2) Upon the written request of an individual who states in writing that methods of diagnosis and treatment of infertility are contrary to such individual’s religious or moral beliefs, any insurance company, hospital or medical service corporation, or health care center may issue to or on behalf of the individual a policy or rider thereto that excludes coverage for such methods.

(d) Any health insurance policy issued pursuant to subsection (c) of this section shall provide written notice to each insured or prospective insured that methods of diagnosis and treatment of infertility are excluded from coverage pursuant to said subsection. Such notice shall appear, in not less than ten-point type, in the policy, application and sales brochure for such policy.

(e) As used in this section, “religious employer” means an employer that is a “qualified church-controlled organization”, as defined in 26 USC 3121 or a church-affiliated organization.

(P.A. 89-120; P.A. 05-196, S. 2.)

History: P.A. 05-196 replaced former provisions with Subsecs. (a) to (e) re required coverage for diagnosis and treatment of infertility, limitations and religious and moral belief exclusions.

See Sec. 38a-509 for similar provisions re individual policies.

Sec. 38a-537. (Formerly Sec. 38-262c). Notice of cancellation or discontinuation to covered employees. Fine. Notice of transfer of coverage. Failure to procure coverage. Retroactive coverage. (a) Any individual, partnership, corporation, or unincorporated association providing group health insurance coverage for its employees shall furnish each insured employee, upon cancellation or discontinuation of such health insurance, notice of the cancellation or discontinuation of such insurance. The notice shall be mailed or delivered to the insured employee not less than fifteen days next preceding the effective date of cancellation or discontinuation. Any individual or any such entity that fails to provide timely notice shall be fined not more than two thousand dollars for each violation. The Labor Commissioner shall have the authority to assess all such fines. This section shall apply to any such individual, partnership, corporation or unincorporated association that substitutes one policy providing group health insurance coverage for another such policy with no interruption in coverage.

(b) If any individual or any such entity fails to furnish notice pursuant to subsection (a) of this section, the individual or entity shall be liable for benefits to the same extent as the insurer, hospital or medical service corporation or health care center would have been liable if coverage had not been cancelled or discontinued.

(c) Any individual, partnership, corporation, or unincorporated association which makes deductions from an employee’s wages for group health insurance coverage and fails to procure such coverage shall be liable for benefits to the same extent as the insurer, hospital or medical service corporation or health care center would have been liable if coverage had been procured. If any corporation makes deductions from an employee’s wages for group health insurance coverage and fails to procure such coverage, any officer of the corporation responsible for procuring such coverage for employees who wilfully failed to procure such coverage shall be personally liable for benefits to the same extent as the insurer, hospital or medical service corporation or health care center would have been liable if coverage had been procured, provided that personal liability shall only be imposed against the officer in the event that an amount owed an employee due to the officer’s failure cannot otherwise be collected from the corporation itself.

(d) Whenever an employer ceases doing business, any terminated employee whose group health insurance was discontinued on or before the date of termination of employment and who did not receive notice of such discontinuation pursuant to subsection (a) of this section shall be eligible for ninety days from the date of discontinuation to purchase as a conversion privilege an individual comprehensive health care plan for himself and any dependents covered by the discontinued group health insurance plan from the former insurer, hospital or medical service corporation, health care center or the Health Reinsurance Association, if any insurer is not issuing such coverage, with coverage retroactive to the date of discontinuation. The employee shall pay the premiums for the period of retroactive coverage. No retroactive coverage may be purchased for a period during which the employee is eligible for benefits under another group plan.

(P.A. 75-402; P.A. 82-159, S. 1; P.A. 85-269; P.A. 89-69; P.A. 90-243, S. 118; P.A. 08-178, S. 17.)

History: P.A. 82-159 provided that notice of “discontinuation” of insurance be given and that, in the event timely notice is not provided, the employer shall be fined in Subsec. (a) and added Subsecs. (b) and (c) providing that the employer who fails to furnish notice shall be liable for benefits to the same extent as the insurer and that retroactive coverage may be purchased by eligible employees; P.A. 85-269 amended Subsec. (a) to grant to the labor commissioner the authority to assess fines under the subsection; P.A. 89-69 added Subsec. (c) concerning the liability of an individual, partnership, corporation or unincorporated association for making deductions for certain insurance coverage and failing to procure the coverage and an officer’s personal liability in such cases; P.A. 90-243 substituted “health” for “life, hospital or medical” insurance, “the” for “such” and added a reference for “health care center”; Sec. 38-262c transferred to Sec. 38a-537 in 1991; P.A. 08-178 amended Subsec. (a) by making technical changes and increasing maximum fine from $1,000 to $2,000 per violation.

Sec. 38a-538. (Formerly Sec. 38-262d). Continuation of benefits under group employee health plans. Each employer shall allow individuals to elect to continue coverage under a group plan pursuant to section 38a-554.

(P.A. 75-417; P.A. 82-340; P.A. 87-274, S. 1; P.A. 90-243, S. 119; P.A. 92-158; May Sp. Sess. P.A. 92-11, S. 69, 70; P.A. 97-268, S. 1; P.A. 10-5, S. 30; 10-13, S. 1.)

History: P.A. 82-340 amended Subsec. (a) to provide extension rights to a former spouse of an employee and require employers to inform individuals of extension rights and individuals, electing such right, to notify employer of such election; P.A. 87-274 expanded the applicability of the section to all group health insurance plans, increased the extension rights for covered individuals from 39 to 78 weeks upon termination of employment and from 39 to 156 weeks upon death or dissolution of marriage, limited payments to 102% of the premium and inserted new Subsec. (b) prohibiting the use of these extension rights if coverage was previously continued under the provisions of COBRA, relettering former Subsec. (b) as (c); P.A. 90-243 applied provisions to health care centers and substituted “health insurance policies” reference for reference to hospital and medical expense policies and contracts; Sec. 38-262d transferred to Sec. 38a-538 in 1991; P.A. 92-158 amended Subsec. (a) by increasing the extension rights for covered individuals from 78 weeks to 104 weeks upon termination of employment; May Sp. Sess. P.A. 92-11 changed the effective date of P.A. 92-158 from October 1, 1992, to May 27, 1992; P.A. 97-268 deleted former Subsecs. (a) and (c) and amended former Subsec. (b) to require employers to allow individuals to elect to continue coverage pursuant to federal COBRA; P.A. 10-5 made technical changes, effective May 5, 2010; P.A. 10-13 changed reference re continuation of coverage from federal COBRA to Sec. 38a-554, effective May 5, 2010.

See Sec. 31-51o for additional continuation of coverage requirements in the event of a relocation or closing of a covered establishment.

Annotations to former section 38-262d:

Cited. 205 C. 166. Cited. 235 C. 107.

Sec. 38a-539. (Formerly Sec. 38-262f). Group hospital or medical expense insurance policy coverage for treatment of alcoholism on an outpatient basis. Section 38a-539 is repealed, effective January 1, 2000.

(P.A. 77-237; 77-614, S. 323, 610; P.A. 79-610, S. 32; P.A. 90-102, S. 2; 90-243, S. 120; P.A. 93-381, S. 9, 39; P.A. 95-257, S. 11, 12, 21, 58; P.A. 99-284, S. 59, 60.)

Sec. 38a-540. (Formerly Sec. 38-262g). Duplication of coverage under group health insurance policies. In any case in which a husband and wife are employed by the same employer and, by reason of their employment, are both eligible for coverage under the terms of any health insurance policy issued under a group plan and by an insurance company, hospital or medical service corporation, health care center or fraternal benefit society, such husband and wife shall not be required as a condition of their employment or as a condition of coverage under such plan, to pay any premium which does not result in greater coverage than would be provided if only one of them were eligible to participate in such group plan.

(P.A. 79-283, S. 1; P.A. 80-248, S. 1; P.A. 90-243, S. 121.)

History: P.A. 80-248 referred to eligibility for coverage under terms of any “health insurance policy ... issued under a group plan and by a carrier ...” rather than coverage under terms of any “accident, health or accident and health insurance policy issued under a group plan”; P.A. 90-243 made technical changes for statutory consistency; Sec. 38-262g transferred to Sec. 38a-540 in 1991.

Sec. 38a-541. (Formerly Sec. 38-262h). Group health policy to allow spouse coverage as both employee and dependent, when. Effect of collective bargaining agreements. Every health insurance policy issued under a group insurance plan and by an insurance company, hospital or medical service corporation, health care center or fraternal benefit society, delivered, issued for delivery or renewed in this state shall allow the spouse of any employee participating in such or any other group insurance plan offered by the same employer to be covered as an employee in addition to being covered as a dependent of such participating employee, except that benefits provided under such combined coverage of the employee as an employee and as a dependent shall not be in excess of one hundred per cent of the charge for the covered expense or service. The provisions of this section shall apply only where a husband and wife are employed by the same employer and by reason of their employment are both participating in a group insurance plan. Nothing in this section shall alter or impair existing group health insurance policies or contracts which have been established pursuant to an agreement which resulted from collective bargaining, and the provisions required by this section shall become effective upon the next regular renewal and completion of such collective bargaining agreement.

(P.A. 79-283, S. 2; P.A. 80-248, S. 2; P.A. 85-362, S. 1, 3; P.A. 90-243, S. 122.)

History: P.A. 80-248 rephrased provisions and added provision re applicability of provisions to existing policies or contracts established pursuant to collective bargaining agreement; P.A. 85-362 clarified that spouses employed by the same employer may be covered as both an employee and as a dependent in any applicable insurance plan offered by the the employer; P.A. 90-243 made technical changes for statutory consistency; Sec. 38-262h transferred to Sec. 38a-541 in 1991.

Sec. 38a-542. Mandatory coverage for treatment of tumors and leukemia. Mandatory coverage for reconstructive surgery, prosthesis, chemotherapy and wigs. Orally administered anticancer medications. (a) Each insurance company, hospital service corporation, medical service corporation, health care center or fraternal benefit society that delivers, issues for delivery, renews, amends or continues in this state group health insurance policies providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 shall provide coverage under such policies for treatment of leukemia, including outpatient chemotherapy, reconstructive surgery, cost of any nondental prosthesis, including any maxillo-facial prosthesis used to replace anatomic structures lost during treatment for head and neck tumors or additional appliances essential for the support of such prosthesis, outpatient chemotherapy following surgical procedures in connection with the treatment of tumors, a wig if prescribed by a licensed oncologist for a patient who suffers hair loss as a result of chemotherapy, and costs of removal of any breast implant which was implanted on or before July 1, 1994, without regard to the purpose of such implantation, which removal is determined to be medically necessary. Such benefits shall be subject to the same terms and conditions applicable to all other benefits under such policies.

(b) Except as provided in subsection (c) of this section, the coverage required by subsection (a) of this section shall provide at least a yearly benefit of one thousand dollars for the costs of removal of any breast implant, five hundred dollars for the surgical removal of tumors, five hundred dollars for reconstructive surgery, five hundred dollars for outpatient chemotherapy, three hundred fifty dollars for a wig and three hundred dollars for a nondental prosthesis, except that for purposes of the surgical removal of breasts due to tumors the yearly benefit for such prosthesis shall be at least three hundred dollars for each breast removed.

(c) The coverage required by subsection (a) of this section shall provide benefits for the reasonable costs of reconstructive surgery on each breast on which a mastectomy has been performed, and reconstructive surgery on a nondiseased breast to produce a symmetrical appearance. Such benefits shall be subject to the same terms and conditions applicable to all other benefits under such policies. For the purposes of this subsection, reconstructive surgery includes, but is not limited to, augmentation mammoplasty, reduction mammoplasty and mastopexy.

(d) (1) Each policy of the type specified in subsection (a) of this section that provides coverage for intravenously administered and orally administered anticancer medications used to kill or slow the growth of cancerous cells that are prescribed by a prescribing practitioner, as defined in section 20-571, shall provide coverage for orally administered anticancer medications on a basis that is no less favorable than intravenously administered anticancer medications.

(2) No insurance company, hospital service corporation, medical service corporation, health care center or fraternal benefit society that delivers, issues for delivery, renews, amends or continues in this state a policy of the type specified in subsection (a) of this section shall reclassify such anticancer medications or increase the coinsurance, copayment, deductible or other out-of-pocket expense imposed under such policy for such medications to achieve compliance with this subsection.

(P.A. 90-243, S. 123; P.A. 94-71, S. 12; P.A. 97-198, S. 4, 5; P.A. 04-34, S. 2; P.A. 10-5, S. 31; 10-63, S. 2; P.A. 11-19, S. 11.)

History: P.A. 94-71 amended Subsec. (a) by adding a provision to cover the cost of removal of any breast implant which was implanted on or before July 1, 1994, without regard to the purpose of the implantation, provided the removal is determined to be medically necessary and added a provision in Subsec. (b) for a benefit of $1,000 for the costs of removal of the breast implant; P.A. 97-198 deleted provision from Subsec. (a) re coverage for the surgical removal of tumors, added exception to Subsec. (b) and added Subsec. (c) re reconstructive surgery after mastectomy, effective July 1, 1997; P.A. 04-34 amended Subsec. (a) to substitute “Each” for “Any” and require coverage for a wig if prescribed for a patient who suffers hair loss as a result of chemotherapy and amended Subsec. (b) to require a yearly benefit of $350 for a wig; P.A. 10-5 made technical changes in Subsecs. (a) and (b), effective January 1, 2011; P.A. 10-63 made technical changes in Subsecs. (a) and (b) and added Subsec. (d) re orally administered anticancer medications, effective January 1, 2011; P.A. 11-19 made technical changes in Subsec. (d).

See Sec. 38a-504 for similar provisions re individual policies.

Sec. 38a-542a. Coverage for routine patient care costs associated with certain clinical trials. Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for the routine patient care costs, as defined in section 38a-542d, associated with clinical trials, in accordance with sections 38a-542b to 38a-542g, inclusive. As used in this section and sections 38a-542b to 38a-542g, inclusive, “clinical trial” means an organized, systematic, scientific study of therapies, tests or other clinical interventions for purposes of treatment or palliation or therapeutic intervention for the prevention of cancer or disabling or life-threatening chronic diseases in human beings.

(P.A. 01-171, S. 1, 25; P.A. 11-19, S. 62; 11-172, S. 8.)

History: P.A. 01-171 effective January 1, 2002; P.A. 11-19 inserted “amended or continued”, redefined “cancer clinical trial” and made a technical change, effective January 1, 2012; P.A. 11-172 inserted “amended or continued”, replaced reference to cancer clinical trials with reference to clinical trials, changed defined term from “cancer clinical trial” to “clinical trial” and redefined same, and made technical changes, effective January 1, 2012.

See Sec. 38a-504a for similar provisions re individual policies.

Sec. 38a-542b. Clinical trial criteria. A clinical trial for the prevention of cancer shall be eligible for coverage only if it involves a therapeutic intervention, is a phase III clinical trial approved by one of the entities identified in this section, and is conducted at multiple institutions. In order to be eligible for coverage of routine patient care costs, as defined in section 38a-542d, a clinical trial shall be (1) conducted under the auspices of an independent peer-reviewed protocol that has been reviewed and approved by: (A) One of the National Institutes of Health; (B) a National Cancer Institute affiliated cooperative group; (C) the federal Food and Drug Administration as part of an investigational new drug or device application or exemption; or (D) the federal Department of Defense or Veterans Affairs; or (2) qualified to receive Medicare coverage of its routine costs under the Medicare Clinical Trial Policy established under the September 19, 2000, Medicare National Coverage Determination, as amended from time to time. Nothing in sections 38a-542a to 38a-542g, inclusive, shall be construed to require coverage for any single institution clinical trial conducted solely under the approval of the institutional review board of an institution, or any trial that is no longer approved by an entity identified in subparagraph (A), (B), (C) or (D) of subdivision (1) of this section.

(P.A. 01-171, S. 2, 25; P.A. 11-19, S. 63; P.A. 11-172, S. 9.)

History: P.A. 01-171 effective January 1, 2002; P.A. 11-19 added provision limiting eligibility of clinical trial for the prevention of cancer, effective January 1, 2012; P.A. 11-172 replaced references to cancer clinical trial with references to clinical trial, designated existing clinical trial criteria as Subdiv. (1) and amended same to insert “application or” re investigational new drug or device, added Subdiv. (2) re Medicare qualification, and made technical changes, effective January 1, 2012.

See Sec. 38a-504b for similar provisions re individual policies.

Sec. 38a-542c. Evidence and information re eligibility for clinical trial. No coverage required for otherwise reimbursable costs. In order to be eligible for coverage of routine patient care costs, as defined in section 38a-542d, the insurer, health care center or plan administrator may require that the person or entity seeking coverage for the clinical trial provide: (1) Evidence satisfactory to the insurer, health care center or plan administrator that the insured person receiving coverage meets all of the patient selection criteria for the clinical trial, including credible evidence in the form of clinical or pre-clinical data showing that the clinical trial is likely to have a benefit for the insured person that is commensurate with the risks of participation in the clinical trial to treat the person’s condition; (2) evidence that the appropriate informed consent has been received from the insured person; (3) copies of any medical records, protocols, test results or other clinical information used by the physician or institution seeking to enroll the insured person in the clinical trial; (4) a summary of the anticipated routine patient care costs in excess of the costs for standard treatment; (5) information from the physician or institution seeking to enroll the insured person in the clinical trial regarding those items, including any routine patient care costs, that are eligible for reimbursement by an entity other than the insurer or health care center, including the entity sponsoring the clinical trial; and (6) any additional information that may be reasonably required for the review of a request for coverage of the clinical trial. The health plan or insurer shall request any additional information about a clinical trial not later than five business days after receiving a request for coverage from an insured person or a physician seeking to enroll an insured person in a clinical trial. Nothing in sections 38a-542a to 38a-542g, inclusive, shall be construed to require the insurer or health care center to provide coverage for routine patient care costs that are eligible for reimbursement by an entity other than the insurer, including the entity sponsoring the clinical trial.

(P.A. 01-171, S. 3, 25; P.A. 11-19, S. 64; 11-172, S. 10.)

History: P.A. 01-171 effective January 1, 2002; P.A. 11-19 made technical changes, effective January 1, 2012; P.A. 11-172 replaced references to cancer clinical trial with references to clinical trial and made technical changes, effective January 1, 2012.

See Sec. 38a-504c for similar provisions re individual policies.

Sec. 38a-542d. Clinical trials: Routine patient care costs. (a) For purposes of sections 38a-542a to 38a-542g, inclusive, “routine patient care costs” means: (1) Medically necessary health care services that are incurred as a result of the treatment being provided to the insured person for purposes of the clinical trial that would otherwise be covered if such services were not rendered pursuant to a clinical trial. Such services shall include those rendered by a physician, diagnostic or laboratory tests, hospitalization or other services provided to the insured person during the course of treatment in the clinical trial for a condition, or one of its complications, that is consistent with the usual and customary standard of care and would be covered if the insured person were not enrolled in a clinical trial. Such hospitalization shall include treatment at an out-of-network facility if such treatment is not available in-network and not eligible for reimbursement by the sponsors of such clinical trial; and (2) costs incurred for drugs provided to the insured person, in accordance with section 38a-518b, provided such drugs have been approved for sale by the federal Food and Drug Administration.

(b) Routine patient care costs shall be subject to the terms, conditions, restrictions, exclusions and limitations of the contract or certificate of insurance between the insured person and the insurer or health plan, including limitations on out-of-network care, except that treatment at an out-of-network hospital as provided in subdivision (1) of subsection (a) of this section shall be made available by the out-of-network hospital and the insurer or health care center at no greater cost to the insured person than if such treatment was available in-network. The insurer or health care center may require that any routine tests or services required under the clinical trial protocol be performed by providers or institutions under contract with the insurer or health care center.

(c) Notwithstanding the provisions of subsection (a) of this section, routine patient care costs shall not include: (1) The cost of an investigational new drug or device that has not been approved for market for any indication by the federal Food and Drug Administration; (2) the cost of a non-health-care service that an insured person may be required to receive as a result of the treatment being provided for the purposes of the cancer clinical trial; (3) facility, ancillary, professional services and drug costs that are paid for by grants or funding for the clinical trial; (4) costs of services that (A) are inconsistent with widely accepted and established regional or national standards of care for a particular diagnosis, or (B) are performed specifically to meet the requirements of the clinical trial; (5) costs that would not be covered under the insured person’s policy for noninvestigational treatments, including, but not limited to, items excluded from coverage under the insured person’s contract with the insurer or health plan; and (6) transportation, lodging, food or any other expenses associated with travel to or from a facility providing the clinical trial, for the insured person or any family member or companion.

(P.A. 01-171, S. 4, 25; P.A. 07-67, S. 2; P.A. 11-19, S. 65; 11-172, S. 11.)

History: P.A. 01-171 effective January 1, 2002; P.A. 07-67 amended Subsec. (a)(1) to require that hospitalization include treatment at out-of-network facility if treatment is not available in-network and not eligible for reimbursement by sponsors of clinical trial, and amended Subsec. (b) to require out-of-network hospitalization to be made available at the in-network level of benefits under the policy or contract, effective May 30, 2007; P.A. 11-19 made technical changes in Subsec. (a), effective January 1, 2012; P.A. 11-172 replaced references to cancer clinical trial with references to clinical trial and made technical changes, effective January 1, 2012.

See Sec. 38a-504d for similar provisions re individual policies.

Sec. 38a-542e. Clinical trials: Billing. Payments. (a) Providers, hospitals and institutions that provide routine patient care services as set forth in subsection (a) of section 38a-542d as part of a clinical trial that meets the requirements of sections 38a-542a to 38a-542g, inclusive, and is approved for coverage by the insurer or health care center shall not bill the insurer or health care center or the insured person for any facility, ancillary or professional services or costs that are not routine patient care services as set forth in subsection (a) of section 38a-542d or for any product or service that is paid by the entity sponsoring or funding the clinical trial.

(b) Providers, hospitals, institutions and insured persons may appeal a health plan’s denials of payment for services only to the extent permitted by the contract between the insurer or health care center and the provider, hospital or institution.

(c) Providers, hospitals or institutions that have contracts with the insurer or health care center to render covered routine patient care services to insured persons as part of a clinical trial shall not bill the insured person for the cost of any covered routine patient care service.

(d) Providers, hospitals or institutions that do not have a contract with the insurer or health care center to render covered routine patient care services to insured persons as part of a clinical trial shall not bill the insured person for the cost of any covered routine patient care service.

(e) Nothing in this section shall be construed to prohibit a provider, hospital or institution from collecting a deductible or copayment as set forth in the insured person’s contract for any covered routine patient care service.

(f) Pursuant to subsection (b) of section 38a-542d, insurers or health care centers shall be required to pay providers, hospitals and institutions that do not have a contract with the insurer or health care center to render covered routine patient care services to insured persons the lesser of (1) the lowest contracted per diem, fee schedule rate or case rate that the insurer or health care center pays to any participating provider in the state of Connecticut for similar in-network services, or (2) the billed charges. Providers, hospitals or institutions shall not collect any amount more than the total amount paid by the insurer or health care center and the insured person in the form of a deductible or copayment set forth in the insured person’s contract. Such amount shall be deemed by the provider, hospital or institution to be payment in full.

(P.A. 01-171, S. 5, 25; P.A. 11-172, S. 12.)

History: P.A. 01-171 effective January 1, 2002; P.A. 11-172 replaced references to cancer clinical trial with references to clinical trial and, in Subsecs. (c), (d) and (f), changed “may not” to “shall not”, effective January 1, 2012.

See Sec. 38a-504e for similar provisions re individual policies.

Sec. 38a-542f. Clinical trials: Standardized forms. Time frame for coverage determinations. Appeals. Regulations. (a)(1) For purposes of cancer clinical trials, the Insurance Department, in cooperation with the Connecticut Oncology Association, the American Cancer Society, the Connecticut Association of Health Plans and Anthem Blue Cross of Connecticut, shall develop a standardized form that all providers, hospitals and institutions shall submit to the insurer or health care center when seeking to enroll an insured person in a cancer clinical trial. An insurer or health care center shall not substitute any other approval request form for the form developed by the department, except that any insurer or health care center that has entered into an agreement to provide coverage for cancer clinical trials approved pursuant to section 38a-542g may use the form or process established by such agreement.

(2) For purposes of clinical trials other than cancer clinical trials, the Insurance Department, in cooperation with at least one state nonprofit research or advocacy organization concerned with the subject of the clinical trial, at least one national nonprofit research or advocacy organization concerned with the subject of the clinical trial, the Connecticut Association of Health Plans and Anthem Blue Cross of Connecticut, shall develop a standardized form that all providers, hospitals and institutions shall submit to the insurer or health care center when seeking to enroll an insured person in a clinical trial. An insurer or health care center shall not substitute any other approval request form for the form developed by the department, except that any insurer or health care center that has entered into an agreement to provide coverage for clinical trials approved pursuant to section 38a-542g, may use the form or process established by such agreement.

(b) Any insurer or health care center that receives the department form from a provider, hospital or institution seeking coverage for the routine patient care costs of an insured person in a clinical trial shall approve or deny coverage for such services not later than five business days after receiving such request and any other reasonable supporting materials requested by the insurer or health plan pursuant to section 38a-542c, except that an insurer or health care center that utilizes independent experts to review such requests shall respond not later than ten business days after receiving such request and supporting materials.

(c) The insured, or the provider with the insured’s written consent, may appeal any denial of coverage for medical necessity to an external, independent review pursuant to section 38a-591g. Such external review shall be conducted by a properly qualified review agent whom the department has determined does not have a conflict of interest regarding the clinical trial.

(d) The Insurance Commissioner shall adopt regulations, in accordance with chapter 54, to implement the provisions of this section.

(P.A. 01-171, S. 6, 25; P.A. 11-19, S. 66; 11-58, S. 84; 11-172, S. 13; P.A. 12-145, S. 21.)

History: P.A. 01-171 effective January 1, 2002; P.A. 11-19 made technical changes in Subsec. (b), effective January 1, 2012; P.A. 11-58 replaced reference to Sec. 38a-478n with “section 38a-591g” in Subsec. (c), effective July 1, 2011; P.A. 11-172 amended Subsec. (a) by designating existing provisions as Subdiv. (1) and amending same to change “may not” to “shall not” and by adding Subdiv. (2) re standardized form for clinical trials other than cancer clinical trials, amended Subsec. (b) by replacing references to cancer clinical trial with references to clinical trial, deleting provision re time period for approval or denial of coverage for phase III clinical trials for prevention of cancer and by making technical changes, and amended Subsec. (c) by replacing reference to cancer clinical trial with reference to clinical trial, effective January 1, 2012; P.A. 12-145 amended Subsec. (a)(2) to replace reference to Sec. 38a-504g with reference to Sec. 38a-542g, effective June 15, 2012.

See Sec. 38a-504f for similar provisions re individual policies.

Sec. 38a-542g. Clinical trials: Submission and certification of policy forms. (a) Any insurer or health care center with coverage policies for care in clinical trials shall submit such policies to the Insurance Department for evaluation and approval. The department shall certify whether the insurer’s or health care center’s coverage policy for routine patient care costs associated with clinical trials is substantially equivalent to the requirements of sections 38a-542a to 38a-542f, inclusive. If the department finds that such coverage is substantially equivalent to the requirements of sections 38a-542a to 38a-542f, inclusive, the insurer or health care center shall be exempt from the provisions of sections 38a-542a to 38a-542f, inclusive.

(b) Any such insurer or health care center shall report annually, in writing, to the department that there have been no changes in the policy as certified by the department. If there has been any change in the policy, the insurer or health care center shall resubmit its policy for certification by the department.

(c) Any insurer or health care center coverage policy found by the department not to be substantially equivalent to the requirements of sections 38a-542a to 38a-542f, inclusive, shall abide by the requirements of sections 38a-542a to 38a-542f, inclusive, until the insurer or health care center has received such certification by the department.

(P.A. 01-171, S. 7, 25; P.A. 11-172, S. 14; P.A. 12-145, S. 17.)

History: P.A. 01-171 effective January 1, 2002; P.A. 11-172 replaced references to cancer clinical trials with references to clinical trials in Subsec. (a), effective January 1, 2012; P.A. 12-145 replaced references to Sec. 38a-542g with references to Sec. 38a-542f, effective June 15, 2012.

See Sec. 38a-504g for similar provisions re individual policies.

Sec. 38a-543. (Formerly Sec. 38-262j). Age discrimination in group insurance coverage prohibited. No individual, partnership, corporation or unincorporated association which employs less than twenty employees and provides group hospital, surgical or medical insurance coverage for its employees may reduce the coverage provided to any employee or any employee’s spouse solely because he has reached the age of sixty-five and is eligible for Medicare benefits except to the extent such coverage is provided by Medicare. The terms of any such plan provided by any such employer which employs twenty or more employees shall entitle any employee who has attained the age of sixty-five and any employee’s spouse who has attained the age of sixty-five to group hospital, surgical or medical insurance coverage under the same conditions as any covered employee or spouse who is under the age of sixty-five.

(P.A. 82-196, S. 2; P.A. 88-303, S. 2, 6; P.A. 90-88, S. 2.)

History: P.A. 88-303 removed the provision for reduced coverage for Medicare-eligible employees and provided that employees and their spouses aged 65 and over are entitled to group health insurance coverage under the same conditions as covered employees and spouses under age 65; P.A. 90-88 allowed for the provision of reduced coverage for Medicare eligible employees of employers with less than 20 employees; Sec. 38-262j transferred to Sec. 38a-543 in 1991.

Sec. 38a-544. Prescription drug coverage. Mail order pharmacies. (a) No medical benefits contract on a group basis, whether issued by an insurance company, a hospital service corporation, a medical service corporation or a health care center, which provides coverage for prescription drugs may require any person covered under such contract to obtain prescription drugs from a mail order pharmacy as a condition of obtaining benefits for such drugs.

(b) The provisions of this section shall apply to any such medical benefits contract delivered, issued for delivery or renewed in this state on or after July 1, 1989.

(P.A. 89-374.)

See Sec. 38a-510 for similar provisions re individual policies.

Sec. 38a-545. (Formerly Sec. 38-262k). Group dental health insurance plans. Alternative coverage option. Any employer or other organization which had twenty-five or more employees or members at all times during the preceding calendar year and which contributes to a group health insurance plan for such employees or members which restricts the covered persons in selecting the providers of dental services to a single provider or limited number of providers, shall also offer each employee or member or their eligible dependents, at the time the dental benefits plan is offered to or renewed for any such person or persons, the option of selecting alternative coverage which permits the covered person to obtain dental services from any licensed dentist of his choice.

(P.A. 83-161; P.A. 90-243, S. 124.)

History: P.A. 90-243 deleted the reference to “group hospital or medical service plan contract”; Sec. 38-262k transferred to Sec. 38a-545 in 1991.

Sec. 38a-546. (Formerly Sec. 38-379). Discontinuation and replacement of group health insurance policy. Regulations. (a) In any case of the discontinuance of a group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (3), (4), (11) and (12) of section 38a-469 and delivered, issued for delivery, renewed, amended or continued in this state and the subsequent replacement of such coverage with another such policy, the succeeding carrier, in applying any deductible, coinsurance or waiting period provisions in its plan, shall give credit for the satisfaction or partial satisfaction of the same or similar provisions under a prior plan providing similar benefits. In the case of deductible or coinsurance provisions, the credit shall apply for the same or overlapping benefit periods and shall be given for expenses actually incurred and applied against the deductible or coinsurance provisions of the prior carrier’s plan during the ninety days preceding the effective date of the succeeding carrier’s plan but only to the extent these expenses are recognized under the terms of the succeeding carrier’s plan and are subject to a similar deductible or coinsurance provision.

(b) The commissioner shall adopt regulations, in accordance with the provisions of chapter 54, covering group coverage discontinuance and replacement.

(c) Nothing in this section shall alter or impair existing group policies which have been established pursuant to an agreement which resulted from collective bargaining, and the provisions required by this section shall become effective upon the next regular renewal and completion of such collective bargaining agreement.

(P.A. 75-616, S. 9, 12; P.A. 86-366, S. 2; P.A. 90-243, S. 156; P.A. 97-268, S. 3; P.A. 10-5, S. 32; P.A. 11-19, S. 13; 11-58, S. 45.)

History: P.A. 86-366 inserted new Subsec. (b) providing that whenever a group health insurance policy is discontinued and subsequently replaced, the succeeding carrier must give credit for the satisfaction of any deductible, coinsurance or waiting period provisions under the prior policy and renumbered previously existing Subsecs. as necessary; P.A. 90-243 inserted reference to “insurance” policies and deleted the reference to “subscriber contracts”; Sec. 38-379 transferred to Sec. 38a-546 in 1991; P.A. 97-268 amended Subsec. (a) to add reference to Subdivisions (1), (2), (3), (4), (11) and (12) of Sec. 38a-469, and to extend application to policies continued in state on or after October 1, 1997; P.A. 10-5 made technical changes in Subsec. (a), effective January 1, 2011; P.A. 11-19 made a technical change in Subsec. (a); P.A. 11-58 deleted former Subsec. (a) re provisions contained in group policies, redesignated existing Subsecs. (b) to (d) as Subsecs. (a) to (c) and amended Subsec. (a) by adding “providing coverage of the type specified in subdivisions (1), (2), (3), (4), (11) and (12) of section 38a-469 and delivered, issued for delivery, renewed, amended or continued in this state”, effective July 2, 2011.

Sec. 38a-547. Termination of policy or contract due to insurer ceasing to offer health insurance in this state; maternity benefits to continue for six weeks following termination of the pregnancy, when. As used in this section, the term “employer” means any individual, partnership, corporation or unincorporated association providing group hospital or medical insurance coverage for its employees. Whenever any insurance company, hospital service corporation or medical service corporation authorized to do the business of health insurance in this state declines to continue or renew a health insurance policy or contract issued to an employer because it is ceasing to offer health insurance within this state, the subsequent termination of coverage for such group shall be without prejudice to any claim for maternity benefits made by any employee or dependent covered under such policy or contract who is pregnant on the date of termination of such group coverage, provided such insurance company, hospital service corporation or medical service corporation is given written notice of any such pregnant employee or dependent within thirty days after the termination date. Maternity benefits and benefits for treatment of medical complications resulting from such pregnancy shall be payable for six weeks following the termination of pregnancy, subject to the terms and conditions of such policy or contract.

(P.A. 90-302; P.A. 93-345, S. 2.)

History: P.A. 93-345 deleted Subsecs. (b) and (c) re preexisting conditions and regulations.

Sec. 38a-548. Penalty. Any insurer, hospital or medical service corporation, health care center or fraternal benefit society, or any officer or agent thereof, delivering or issuing for delivery to any person in this state any policy in violation of any of the provisions of sections 38a-512 to 38a-533, inclusive, 38a-537 to 38a-542, inclusive, and 38a-545, shall be fined not more than one thousand dollars for each offense, and the commissioner may revoke the license of any foreign or alien insurer, or any agent thereof, violating any of those provisions.

(P.A. 90-243, S. 125; P.A. 08-178, S. 18.)

History: P.A. 08-178 increased maximum fine from $500 to $1,000 per offense.

Sec. 38a-549. Coverage for adopted children. (a) Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state shall provide coverage for a child legally placed for adoption with an employee or other member of the covered group who is an adoptive parent or a prospective adoptive parent, even though the adoption has not been finalized, provided the child lives in the household of such employee or member and the child is dependent upon such employee or member for support and maintenance.

(b) Coverage for such child legally placed for adoption shall consist of coverage for injury and sickness including necessary care and treatment of medically diagnosed congenital defects and birth abnormalities within the limits of the policy.

(c) If payment of a specific premium or subscription fee is required to provide coverage for a child legally placed for adoption with the insured or subscriber who is an adoptive parent or a prospective adoptive parent, the policy may require that notification of acceptance of such child and payment of the required premium or fees be furnished to the insurer, hospital or medical service corporation or health care center within thirty-one days after the acceptance of such child in order to continue coverage beyond such thirty-one-day period, provided failure to furnish such notice or pay such premium or fees shall not prejudice any claim originating within such thirty-one-day period.

(d) Such policy (1) shall cover such child legally placed for adoption on the same basis as other dependents, and (2) may not contain any provision concerning preexisting conditions, insurability, eligibility or health underwriting approval for a child legally placed for adoption, except that an insurer, hospital or medical service corporation or health care center may require health underwriting for a child legally placed for adoption if a required premium or subscription fee and completed application materials are not provided to the insurer, hospital or medical service corporation or health care center before the expiration of the thirty-one-day period following the date the child was legally placed for adoption.

(P.A. 91-97, S. 2; P.A. 02-96, S. 2; P.A. 03-70, S. 2.)

History: P.A. 02-96 amended Subsec. (a) to substitute “each” for “every” and “amended, renewed or continued in this state” for “amended or renewed in this state on or after October 1, 1991,” and added Subsec. (d) re coverage and prohibited provisions; P.A. 03-70 amended Subsec. (c) to substitute “premium or subscription fee” for “premium fee” and amended Subsec. (d) to add exception re health underwriting if required premium or subscription fee and completed application materials are not provided before expiration of thirty-one-day period.

See Sec. 38a-508 for similar provisions re individual policies.

Sec. 38a-550. Copayments re in-network imaging services. (a) No health insurer, health care center, hospital service corporation, medical service corporation or fraternal benefit society that provides coverage under a group health insurance policy or contract for magnetic resonance imaging or computed axial tomography may (1) require total copayments in excess of three hundred seventy-five dollars for all such in-network imaging services combined annually, or (2) require a copayment in excess of seventy-five dollars for each in-network magnetic resonance imaging or computed axial tomography, provided the physician ordering the radiological services and the physician rendering such services are not the same person or are not participating in the same group practice.

(b) No health insurer, health care center, hospital service corporation, medical service corporation or fraternal benefit society that provides coverage under a group health insurance policy or contract for positron emission tomography may (1) require total copayments in excess of four hundred dollars for all such in-network imaging services combined annually, or (2) require a copayment in excess of one hundred dollars for each in-network positron emission tomography, provided the physician ordering the radiological service and the physician rendering such service are not the same person or are not participating in the same group practice.

(c) The provisions of subsections (a) and (b) of this section shall not apply to a high deductible health plan as that term is used in subsection (f) of section 38a-520.

(P.A. 06-180, S. 2; P.A. 07-54, S. 4.)

History: P.A. 07-54 made technical changes in Subsecs. (a) and (b), effective May 22, 2007.

See Sec. 38a-511 for similar provisions re individual policies.

PART IV

COMPREHENSIVE HEALTH CARE PLANS

Sec. 38a-551. (Formerly Sec. 38-371). Definitions. For the purposes of this section and sections 38a-552 to 38a-559, inclusive, the following terms shall have the following meanings:

(a) “Health insurance” means hospital and medical expenses incurred policies written on a direct basis, nonprofit service plan contracts, health care center contracts and self-insured or self-funded employee health benefit plans. For purposes of sections 38a-505, 38a-546 and 38a-551 to 38a-559, inclusive, “health insurance” does not include (1) accident only, credit, dental, vision, Medicare supplement, long-term care or disability insurance, hospital indemnity coverage, coverage issued as a supplement to liability insurance, insurance arising out of a workers’ compensation or similar law, automobile medical-payments insurance, or insurance under which beneficiaries are payable without regard to fault and which is statutorily required to be contained in any liability insurance policy or equivalent self-insurance, or (2) policies of specified disease or limited benefit health insurance, provided: (A) The carrier offering such policies files on or before March first of each year a certification with the commissioner that contains the following: (i) A statement from the carrier certifying that such policies are being offered and marketed as supplemental health insurance and not as a substitute for hospital or medical expense insurance; and (ii) a summary description of each such policy including the average annual premium rates, or range of premium rates in cases where premiums vary by age, gender or other factors, charged for such policy in the state; and (B) for each such policy that is offered for the first time in this state on or after July 1, 2005, the carrier files with the commissioner the information and statement required in subparagraph (A) of this subdivision at least thirty days prior to the date such policy is issued or delivered in this state.

(b) “Carrier” means an insurer, health care center, hospital service corporation or medical service corporation or fraternal benefit society.

(c) “Insurer” means an insurance company licensed to transact accident and health insurance business in this state.

(d) “Health care center” means a health care center, as defined in section 38a-175.

(e) “Self-insurer” means an employer or an employee welfare benefit fund or plan which provides payment for or reimbursement of the whole or any part of the cost of covered hospital or medical expenses for covered individuals. For purposes of sections 38a-505, 38a-546 and 38a-551 to 38a-559, inclusive, “self-insurer” shall not include any such employee welfare benefit fund or plan established prior to April 1, 1976, by any organization which is exempt from federal income taxes under the provisions of Section 501 of the United States Internal Revenue Code and amendments thereto and legal interpretations thereof, except any such organization described in Subsection (c)(15) of said Section 501.

(f) “Commissioner” means the Insurance Commissioner of the state of Connecticut.

(g) “Physician” means a doctor of medicine, chiropractic, natureopathy, podiatry, a qualified psychologist and, for purposes of oral surgery only, a doctor of dental surgery or a doctor of medical dentistry and, subject to the provisions of section 20-138d, optometrists duly licensed under the provisions of chapter 380.

(h) “Qualified psychologist” means a person who is duly licensed or certified as a clinical psychologist and has a doctoral degree in and at least two years of supervised experience in clinical psychology in a licensed hospital or mental health center.

(i) “Skilled nursing facility” shall have the same meaning as “skilled nursing facility”, as defined in Section 1395x, Chapter 7 of Title 42, United States Code.

(j) “Hospital” shall have the same meaning as “hospital”, as defined in Section 1395x, Chapter 7 of Title 42, United States Code.

(k) “Home health agency” shall have the same meaning as “home health agency”, as defined in Section 1395x, Chapter 7 of Title 42, United States Code.

(l) “Copayment” means the portion of a charge that is covered by a plan and not payable by the plan and which is thus the obligation of the covered individual to pay.

(m) “Resident employer” means any person, partnership, association, trust, estate, limited liability company, corporation, whether foreign or domestic, or the legal representative, trustee in bankruptcy or receiver or trustee, thereof, or the legal representative of a deceased person, including the state of Connecticut and each municipality therein, which has in its employ one or more individuals during any calendar year, commencing January 1, 1976. For purposes of sections 38a-505, 38a-546 and 38a-551 to 38a-559, inclusive, the term “resident employer” shall refer only to an employer with a majority of employees employed within the state of Connecticut.

(n) “Eligible employee” means, with respect to any employer, an employee who either is considered a full-time employee, or who is expected to work at least twenty hours a week for at least twenty-six weeks during the next twelve months or who has actually worked at least twenty hours a week for at least twenty-six weeks in any continuous twelve-month period.

(o) “Alcoholism treatment facility” shall have the same meaning as in section 38a-533.

(p) “Totally disabled” means with respect to an employee, the inability of the employee because of an injury or disease to perform the duties of any occupation for which he is suited by reason of education, training or experience, and, with respect to a dependent, the inability of the dependent because of an injury or disease to engage in substantially all of the normal activities of persons of like age and sex in good health.

(q) “Deductible” means the amount of covered expenses which must be accumulated during each calendar year before benefits become payable as additional covered expenses incurred.

(r) For purposes of sections 38a-505, 38a-546 and 38a-551 to 38a-559, inclusive, “disease or injury” shall include pregnancy and resulting childbirth or miscarriage.

(s) “Complications of pregnancy” means (1) conditions requiring hospital stays, when the pregnancy is not terminated, whose diagnoses are distinct from pregnancy but are adversely affected by pregnancy or are caused by pregnancy, such as acute nephritis, nephrosis, cardiac decompensation, missed abortion and similar medical and surgical conditions of comparable severity, and shall not include false labor, occasional spotting, physician-prescribed rest during the period of pregnancy, morning sickness, hyperemesis gravidarum, pre-eclampsia and similar conditions associated with management of a difficult pregnancy not constituting a nosologically distinct complication of pregnancy; and (2) nonelective caesarean section, ectopic pregnancy which is terminated, and spontaneous termination of pregnancy, which occurs during a period of gestation in which a viable birth is not possible.

(t) “Resident” means (1) a person who maintains a residence in this state for a period of at least one hundred eighty days, or (2) a HIPAA or health care tax credit eligible individual who maintains a residence in this state.

(u) “HIPAA eligible individual” means an eligible individual as defined in subsection (b) of section 2741 of the Public Health Service Act, as set forth in the Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191) (HIPAA).

(v) “Health care tax credit eligible individual” means a person who is eligible for the credit for health insurance costs under Section 35 of the Internal Revenue Code of 1986 in accordance with the Pension Benefit Guaranty Corporation and Trade Adjustment Assistance programs of the Trade Act of 2002 (P.L. 107-210).

(P.A. 75-616, S. 1, 12; P.A. 76-399, S. 2, 5; P.A. 77-614, S. 163, 610; P.A. 80-482, S. 331, 345, 348; P.A. 90-243, S. 154; P.A. 91-100, S. 1; P.A. 93-338, S. 1; P.A. 95-79, S. 143, 189; June 18 Sp. Sess. P.A. 97-8, S. 67, 72, 88; P.A. 99-102, S. 45; P.A. 01-174, S. 11; June 30 Sp. Sess. P.A. 03-6, S. 66; P.A. 05-270, S. 1.)

History: P.A. 76-399 added Subdivs. (o) to (r) defining “totally disabled”, “deductible”, “disease or injury” and “complications of pregnancy”; P.A. 77-614 placed insurance commissioner within the department of business regulation and made insurance department a division within that department, effective January 1, 1979; P.A. 80-482 restored insurance commissioner and division to prior independent status and abolished the department of business regulation; P.A. 90-243 made technical changes for statutory consistency; Sec. 38-371 transferred to Sec. 38a-551 in 1991; P.A. 91-100 added Subdiv. (s) to define “resident”; P.A. 93-338 in Subdiv. (a) added references to “health care center contracts” in definition of “health insurance”, in Subdiv. (b) added reference to “health care center” in definition of “carrier”, inserted new Subdiv. (d) defining “health care center” and relettered the former Subdivs. (e) to (t), inclusive, accordingly; P.A. 95-79 redefined “resident employer” to include a limited liability company, effective May 31, 1995; June 18 Sp. Sess. P.A. 97-8 redefined “resident” in Subsec. (t) to include HIPAA eligible individual who maintains a residence in this state, and added new Subsec. (u) to define “HIPAA eligible individual”, effective July 1, 1997; P.A. 99-102 amended Subsec. (g) by deleting an obsolete reference to osteopathy and making a technical change; P.A. 01-174 substituted reference to Sec. 38a-696 for Sec. 38a-697 in Subsec. (a); June 30 Sp. Sess. P.A. 03-6 made a technical change in Subsecs. (d), (i), (j) and (k), amended Subsec. (t) to include in definition of “resident” a health care tax credit eligible individual and make a technical change, and added Subsec. (v) defining “health care tax credit eligible individual”, effective August 20, 2003; P.A. 05-270 redefined “health insurance” in Subsec. (a), effective July 1, 2005.

Sec. 38a-552. (Formerly Sec. 38-372). Applicability. Individual and group comprehensive health care plans. (a)(1) Every carrier offering individual health insurance in this state shall, as a condition of transacting such health insurance, make an individual comprehensive health care plan, described in section 38a-555, available to every resident of this state except residents who are both sixty-five years of age or older and eligible for Medicare. Individual comprehensive health care plans may be made available through participation in the Health Reinsurance Association in accordance with section 38a-556, or a residual market association, in accordance with section 38a-557. The premium charged for such a plan which is not insured by or through the Health Reinsurance Association or any other residual market association may not exceed the premium which would be applicable through participation in such associations. The premium charged for such a plan insured by or through the Health Reinsurance Association shall be precisely the premium established for that particular classification under the Health Reinsurance Association. (2) Every self-insurer whose plan covers three or more employees shall make an individual comprehensive health care plan, described in section 38a-555, available under a conversion privilege to every person covered by the plan who is a resident of this state, who is not eligible for Medicare and whose coverage under the self-insured plan ceases as a result of layoff, death or termination of employment. The individual comprehensive health care plans may be provided through a carrier or through participation in the Health Reinsurance Association in accordance with section 38a-556. The premium charged for such a plan which is not insured by or through the Health Reinsurance Association may not exceed the premium established for that particular classification under the Health Reinsurance Association. The premium charged for such a plan which is insured by or through the Health Reinsurance Association shall be precisely the premium established for that particular classification under the Health Reinsurance Association.

(b) Every carrier offering group health insurance in this state shall, as a condition of transacting such health insurance, make a group comprehensive health care plan, as described in section 38a-554, available to every resident employer who is not a small employer as defined in subdivision (4) of section 38a-564.

(c) Except as provided in subdivision (c) of section 38a-505, nothing in sections 38a-505, 38a-546 and 38a-551 to 38a-559, inclusive, shall preclude the right of carriers to transact other kinds of insurance for which they are authorized, nor preclude the right of carriers to transact any other lawful kind of health insurance.

(d) Nothing in sections 38a-505, 38a-546 and 38a-551 to 38a-559, inclusive, shall require a carrier to make available coverage under a group or individual comprehensive health care plan to any person or group who is already covered under such a plan.

(P.A. 75-616, S. 2, 12; P.A. 86-106, S. 1; P.A. 90-134, S. 24, 28; P.A. 91-201, S. 5, 8; P.A. 93-338, S. 4; 93-435, S. 69.)

History: P.A. 86-106 limited the exemption from the required availability of individual comprehensive health care plans to those residents of this state who are at least 65 years of age and eligible for Medicare; P.A. 90-134 removed language in Subsec. (b) pertaining to group comprehensive plans for employers of between 3 and 25 employees; Sec. 38-372 transferred to Sec. 38a-552 in 1991; P.A. 91-201 made technical changes re definition of “small employer”; P.A. 93-338 deleted in Subsecs. (a) and (b) the individual comprehensive health care plan option choices for both individuals and employers; P.A. 93-345 amended Subsec. (a)(1) to delete the requirement that an individual comprehensive health care plan shall include the choice of a low option or middle option or high option deductible.

Sec. 38a-553. (Formerly Sec. 38-373). Minimum standard benefits of comprehensive health care plans. Optional and excludable benefits. Preexisting conditions. Use of managed care plans. All individual and all group comprehensive health care plans shall include minimum standard benefits as described in this section.

(a) Except as provided in subsections (b) and (c), minimum standard benefits shall be benefits, including coverage for catastrophic illness, with a lifetime maximum of one million dollars per individual, for reasonable charges or, when applicable, the allowance agreed upon between a provider and a carrier for charges actually incurred, for the following health care services, rendered to an individual covered by such plan for the diagnosis or treatment of nonoccupational disease or injury: (1) Hospital services; (2) professional services which are rendered by a physician or, at his direction, by a registered nurse, other than services for mental or dental conditions; (3) the diagnosis or treatment of mental conditions, in accordance with the minimum requirements established in section 38a-514; (4) legend drugs requiring a prescription of a physician, advanced practice registered nurse or physician assistant; (5) services of a skilled nursing facility for not more than one hundred twenty days in a calendar year, provided such services commence within fourteen days following a confinement of at least three consecutive days in a hospital for the same condition; (6) home health agency services, as defined by the commissioner, up to a maximum of one hundred eighty visits in a calendar year, provided such services commence within seven days following confinement in a hospital or skilled nursing facility of at least three consecutive days for the same condition, provided further, in the case of an individual diagnosed by a physician as terminally ill with a prognosis of six months or less to live, such home health agency services may commence irrespective of whether such covered person was so confined or, if such covered person was so confined, irrespective of such seven-day period, and the yearly benefit for medical social services, as hereinafter defined, shall not exceed two hundred dollars. “Medical social services” means services rendered, under the direction of a physician by a qualified social worker holding a master’s degree from an accredited school of social work, including but not limited to (A) assessment of the social, psychological and family problems related to or arising out of such covered person’s illness and treatment; (B) appropriate action and utilization of community resources to assist in resolving such problems; (C) participation in the development of treatment for such covered person; (7) use of radium or other radioactive materials; (8) outpatient chemotherapy for the removal of tumors and treatment of leukemia, including outpatient chemotherapy; (9) oxygen; (10) anesthetics; (11) nondental prosthesis and maxillo-facial prosthesis used to replace any anatomic structure lost during treatment for head and neck tumors or additional appliances essential for the support of such prosthesis; (12) rental of durable medical equipment which has no personal use in the absence of the condition for which prescribed; (13) diagnostic x-rays and laboratory tests as defined by the commissioner; (14) oral surgery for: (A) Excision of partially or completely unerupted impacted teeth, or (B) excision of a tooth root without the extraction of the entire tooth; (15) services of a licensed physical therapist, rendered under the direction of a physician; (16) transportation by a local professional ambulance to the nearest health care institution qualified to treat the illness or injury; (17) certain other services which are medically necessary in the treatment or diagnosis of an illness or injury as may be designated or approved by the Insurance Commissioner; (18) confinement in a facility established primarily for the treatment of alcoholism and licensed for such care by the state, or in a part of a hospital used primarily for such treatment, shall be a covered expense for a period of at least forty-five days within any calendar year.

(b) Minimum standard benefits may include one or more of the following provisions: (1) For policies issued or renewed prior to April 1, 1994, subject to the provisions of subdivision (3) such plan may require deductibles. The “low option deductible” shall be two hundred dollars per person, the “middle option deductible” shall be five hundred dollars per person, and the “high option deductible” shall be seven hundred fifty dollars per person. The amount of the deductible may not be greater when a service is rendered on an outpatient basis than when that service is offered on an inpatient basis. Expenses incurred during the last three months of a calendar year and actually applied to an individual’s deductible for that year shall be applied to that individual’s deductible in the following calendar year. The two-hundred-dollar maximum, the five-hundred-dollar maximum and the seven-hundred-fifty-dollar maximum may be adjusted yearly to correspond with the change in the medical care component of the Consumer Price Index, as adjusted by the commissioner. The base year for such computation shall be the first full year of operation of such plan. (2) For policies issued or renewed prior to April 1, 1994, subject to the provisions of subdivision (3), such plan shall require a maximum copayment of twenty per cent for charges for all types of health care in excess of the deductible and fifty per cent for services listed in subdivision (3) of subsection (a) in excess of the deductible. (3) The sum of any deductible and copayments required in any calendar year may not exceed a maximum limit of one thousand dollars per covered individual, or two thousand dollars per covered family; provided, covered expenses incurred after the applicable maximum limit has been reached shall be paid at the rate of one hundred per cent, except that expenses incurred for treatment of mental and nervous conditions may be paid at the rate of fifty per cent as specified in subdivision (3) of subsection (a). The one-thousand-dollar and two-thousand-dollar maximums shall be adjusted yearly to correspond with the change in the medical care component of the Consumer Price Index as adjusted by the commissioner. (4) The plan shall limit benefits with respect to each pregnancy, other than a pregnancy involving complications of pregnancy, to a maximum of two hundred fifty dollars. (5) The plan may limit lifetime benefits to a maximum of not less than one million dollars per covered individual. (6) No preexisting condition exclusion shall exclude coverage of any preexisting condition unless: (A) The condition first manifested itself within the period of six months immediately prior to the effective date of coverage in such a manner as would cause a reasonably prudent person to seek diagnosis, care or treatment; (B) medical advice or treatment was recommended or received within the period of six months immediately prior to the effective date of coverage; or (C) the condition is pregnancy existing on the effective date of coverage. No policy shall exclude coverage for a loss due to preexisting conditions for a period greater than twelve months following the effective date of coverage. Any individual comprehensive health care plan issued as a result of conversion from group health insurance or from a self-insured group shall credit the time covered under such group health insurance toward any such exclusion.

(c) Plans providing minimum standard benefits need not provide benefits for the following: (1) Any charge for any care for any injury or disease either (A) arising out of and in the course of an employment subject to a workers’ compensation or similar law or where such benefit is required to be provided under a workers’ compensation policy to a sole proprietor, business partner or corporation officer who elects such coverage pursuant to the provisions of chapter 568, or (B) to the extent benefits are payable without regard to fault under a coverage statutorily required to be contained in any motor vehicle or other liability insurance policy or equivalent self-insurance; (2) any charge for treatment for cosmetic purposes other than surgery for the prompt repair of an accidental injury sustained while covered, provided cosmetic shall not mean replacement of any anatomic structure removed during treatment of tumors; (3) any charge for travel, other than transportation by local professional ambulance to the nearest health care institution qualified to treat the illness or injury; (4) any charge for private room accommodations to the extent it is in excess of the institution’s most common charge for a semiprivate room; (5) any charge by health care institutions to the extent that it is determined by the carrier that the charge exceeds the rates approved by the Office of Health Care Access division of the Department of Public Health; (6) any charge for services or articles to the extent that it exceeds the reasonable charge in the locality for the service; (7) any charge for services or articles which are determined not to be medically necessary, except that this shall not apply to the fabrication or placement of the prosthesis as specified in subdivision (11) of subsection (a) of this section and subdivision (2) of this subsection; (8) any charge for services or articles the provisions of which is not within the scope of the license or certificate of the institution or individual rendering such services or articles; (9) any charge for services or articles furnished, paid for or reimbursed directly by or under any law of a government, except as otherwise provided in this subsection; (10) any charge for services or articles for custodial care or designed primarily to assist an individual in meeting his activities of daily living; (11) any charge for services which would not have been made if no insurance existed or for which the covered individual is not legally obligated to pay; (12) any charge for eyeglasses, contact lenses or hearing aids or the fitting thereof; (13) any charge for dental care not specifically covered by sections 38a-505, 38a-546 and 38a-551 to 38a-559, inclusive; and (14) any charge for services of a registered nurse who ordinarily resides in the covered individual’s home, or who is a member of the covered individual’s family or the family of the covered individual’s spouse.

(d) and (e) Repealed by P.A. 84-499, S. 2.

(f) The minimum standard benefits of any individual or group comprehensive health care plan may be satisfied by catastrophic coverage offered in conjunction with basic hospital or medical-surgical plans on an expense incurred or service basis as approved by the commissioner as providing at least equivalent benefits.

(g) Comprehensive health care plan carriers may offer alternative policy provisions and benefits, including cost containment features, consistent with the purposes of sections 38a-505, 38a-546 and 38a-551 to 38a-559, inclusive, provided such alternative provisions and benefits are approved by the Insurance Commissioner prior to their use. Cost containment features may include, but shall not be limited to, preferred provider provisions; utilization review of health care services, including review of the medical necessity of hospital and physician services; case management benefit alternatives; and other managed care provisions.

(h) Every comprehensive health care plan issued or renewed through the Health Reinsurance Association on or after April 1, 1994, shall be a managed care plan. Such managed care plans shall include one or more health care center plans or preferred provider network plans, as determined by the board of the association, with the approval of the commissioner. In the event that such managed care plans would not adequately serve enrollees in a particular area of the state, the board may offer to such enrollees a managed care product which contains alternative cost containment features, including but not limited to, utilization review of health care services, review of the medical necessity of hospital and physician services and case management benefit alternatives.

(i) No comprehensive health care plan issued through the Health Reinsurance Association to a HIPAA eligible individual shall include any limitation or exclusion of benefits based on a preexisting condition.

(j) No comprehensive health care plan issued through the Health Reinsurance Association to a health care tax credit eligible individual shall include any limitation or exclusion of benefit based on a preexisting condition if such individual maintained creditable health insurance coverage for an aggregate period of three months as of the date on which the individual seeks to enroll in the Health Reinsurance Association issued plan, not counting any period prior to a sixty-three-day break in coverage.

(k) (1) Each comprehensive health care plan issued through the Health Reinsurance Association shall provide coverage, under the terms and conditions of the plan, for the preexisting conditions of any group member or dependent who is newly insured under the plan on or after October 1, 2005, and was previously covered for such preexisting condition under the terms of the group member’s or dependent’s preceding qualifying coverage, provided the preceding qualifying coverage was continuous to a date less than one hundred twenty days prior to the effective date of the new coverage, exclusive of any applicable waiting period, except in the case of a newly insured group member whose preceding qualifying coverage was terminated due to an involuntary loss of employment, the preceding qualifying coverage must have been continuous to a date not more than one hundred fifty days prior to the effective date of the new coverage under the plan, exclusive of any applicable waiting period, provided the requirements of this subdivision shall only apply if the newly insured group member or dependent applies for such succeeding coverage not later than thirty days after the first day of the member’s or dependent’s initial eligibility.

(2) With respect to a group member or dependent who was newly insured under the plan on or after October 1, 2005, and was previously covered under qualifying coverage, but was not covered under such qualifying coverage for a preexisting condition, as defined under the newly issued comprehensive health care plan, such plan shall credit the time such group member or dependent was previously covered by qualifying coverage to the exclusion period of the preexisting condition provision, provided the preceding qualifying coverage was continuous to a date less than one hundred twenty days prior to the effective date of the new coverage, exclusive of any applicable waiting period under such plan, except in the case of a newly insured group member whose preceding qualifying coverage was terminated due to an involuntary loss of employment, the preceding qualifying coverage must have been continuous to a date not more than one hundred fifty days prior to the effective date of the new coverage, exclusive of any applicable waiting period, provided the requirements of this subdivision shall only apply if such newly insured group member or dependent applies for such succeeding coverage not later than thirty days after the first day of the member’s or dependent’s initial eligibility.

(3) As used in this subsection, “qualifying coverage” means coverage under (A) any group health insurance plan, group insurance arrangement or self-insured plan covering a group, (B) Medicare or Medicaid, or (C) an individual health insurance plan that provides benefits which are actuarially equivalent to or exceeding the benefits provided under a small employer health care plan, as defined in section 38a-564, whether issued in this state or any other state, as determined by the Insurance Department.

(P.A. 75-616, S. 3, 12; P.A. 76-399, S. 3, 5; P.A. 77-614, S. 163, 610; P.A. 78-76, S. 4; P.A. 79-327, S. 1; 79-376, S. 67; P.A. 80-482, S. 332, 348; P.A. 81-55; P.A. 82-112; P.A. 84-499, S. 2; P.A. 89-80; P.A. 93-338, S. 2; P.A. 95-257, S. 39, 58; P.A. 96-19, S. 8; June 18 Sp. Sess. P.A. 97-8, S. 68, 88; June 30 Sp. Sess. P.A. 03-6, S. 67; P.A. 04-10, S. 12; P.A. 05-271, S. 1; P.A. 10-179, S. 110.)

History: P.A. 76-399 added Subsec. (a)(17) re coverage pertaining to treatment of alcoholism and added provisions re pregnancy benefits in Subsec. (b); P.A. 77-614 placed insurance commissioner within the department of business regulation and made insurance department a division within that department, effective January 1, 1979; P.A. 78-76 added proviso in Subsec. (a)(6) re coverage of medical social services where patient is terminally ill; P.A. 79-327 inserted new Subdiv. (8) in Subsec. (a) re outpatient chemotherapy and deleted former Subdiv. (16) re unspecified services left to insurance commissioner’s discretion, renumbering as necessary and included maxillo-facial prostheses in Subdiv. (11), formerly (10), amending Subsec. (c) re prostheses accordingly; P.A. 79-376 replaced “workmen’s compensation” with “workers’ compensation” in Subsec. (c)(1); P.A. 80-482 restored insurance commissioner and division to prior independent status and abolished the department of business regulation; P.A. 81-55 amended Subsec. (c), providing that comprehensive health care plans are not obligated to provide benefits for care for injury or disease where benefits must be provided to a sole proprietor or partner under a workers’ compensation policy; P.A. 82-112 provided that comprehensive health care plans need not provide benefits when such benefit is required under workers’ compensation for corporation officers in Subsec. (c) and enumerated certain circumstances under which carriers shall not deny benefits in new Subsec. (d), relettering former Subsecs. (d) and (e) accordingly; P.A. 84-499 repealed Subsecs. (d) and (e) re denial of benefits and carriers’ rights of recovery; P.A. 89-80 added Subsec. (g) allowing alternative provisions and benefits, including cost containment features, to be offered if approved by the commissioner; Sec. 38-373 transferred to Sec. 38a-553 in 1991; P.A. 93-338 in Subsec. (a)(3) changed the provisions re minimum standard benefits for mental illness conditions, in Subsec. (b) specified that Subdivs. (1) and (2) apply to policies issued or renewed prior to April 1, 1994, and added new Subsec. (h) requiring that every plan issued or renewed through the Health Reinsurance Association on or after April 1, 1994, be a managed care plan; P.A. 95-257 replaced Commission on Hospitals and Health Care with Office of Health Care Access, effective July 1, 1995; P.A. 96-19 amended Subsec. (a) to include prescriptions by advanced practice registered nurses and physician assistants; June 18 Sp. Sess. P.A. 97-8 added new Subsec. (i) to prohibit the limitation or exclusion of benefits based on preexisting conditions, effective July 1, 1997; June 30 Sp. Sess. P.A. 03-6 added Subsec. (j) re limitation or exclusion of benefit based on preexisting condition in comprehensive health care plans issued to health care tax credit eligible individuals, effective August 20, 2003; P.A. 04-10 changed “policy” to “plan” in Subsec. (j); P.A. 05-271 added new Subsec. (k) re preexisting conditions for members or dependents newly insured on or after October 1, 2005, and defining “qualifying coverage”; P.A. 10-179 amended Subsec. (c) by making technical changes in Subdivs. (1) and (9) and replacing “Office of Health Care Access” with “Office of Health Care Access division of the Department of Public Health” in Subdiv. (5).

See Sec. 38a-504 re insurance policy or contract requirements covering surgical removal of tumors and treatment of leukemia.

Annotations to former section 38-373:

Subsec. (c):

Subdiv. (1)(B) cited. 186 C. 507.

Subdiv. (1)(B) cited. 36 CS 561.

Sec. 38a-554. (Formerly Sec. 38-374). Additional requirements and eligibility under group comprehensive health care plans. Coverage for stepchildren. Continuation of benefits under group plans. Insurance Commissioner’s authority to coordinate benefits. A group comprehensive health care plan shall contain the minimum standard benefits prescribed in section 38a-553 and shall also conform in substance to the requirements of this section.

(a) The plan shall be one under which the individuals eligible to be covered include: (1) Each eligible employee; (2) the spouse of each eligible employee, who shall be considered a dependent for the purposes of this section; and (3) unmarried children who are under twenty-six years of age. Each plan shall cover a stepchild on the same basis as a biological child.

(b) The plan shall provide the option to continue coverage under each of the following circumstances until the individual is eligible for other group insurance, except as provided in subdivisions (3) and (4) of this subsection:

(1) Notwithstanding any provision of this section, upon layoff, reduction of hours, leave of absence or termination of employment, other than as a result of death of the employee or as a result of such employee’s “gross misconduct” as that term is used in 29 USC 1163(2), continuation of coverage for such employee and such employee’s covered dependents for a period of thirty months after the date of such layoff, reduction of hours, leave of absence or termination of employment, except that if such reduction of hours, leave of absence or termination of employment results from an employee’s eligibility to receive Social Security income, continuation of coverage for such employee and such employee’s covered dependents until midnight of the day preceding such person’s eligibility for benefits under Title XVIII of the Social Security Act;

(2) Upon the death of the employee, continuation of coverage for the covered dependents of such employee for the periods set forth for such event under federal extension requirements established by the Consolidated Omnibus Budget Reconciliation Act of 1985, P.L. 99-272, as amended from time to time;

(3) Regardless of the employee’s or dependent’s eligibility for other group insurance, during an employee’s absence due to illness or injury, continuation of coverage for such employee and such employee’s covered dependents during continuance of such illness or injury or for up to twelve months from the beginning of such absence;

(4) Regardless of an individual’s eligibility for other group insurance, upon termination of the group plan, coverage for covered individuals who were totally disabled on the date of termination shall be continued without premium payment during the continuance of such disability for a period of twelve calendar months following the calendar month in which the plan was terminated, provided claim is submitted for coverage within one year of the termination of the plan;

(5) The coverage of any covered individual shall terminate: (A) As to a child, the plan shall provide the option for said child to continue coverage for the longer of the following periods: (i) At the end of the month following the month in which the child: Marries; ceases to be a resident of the state; becomes covered under a group health plan through the dependent’s own employment; or attains the age of twenty-six. The residency requirement shall not apply to dependent children under nineteen years of age or full-time students attending an accredited institution of higher education. If on the date specified for termination of coverage on a child, the child is unmarried and incapable of self-sustaining employment by reason of mental or physical handicap and chiefly dependent upon the employee for support and maintenance, the coverage on such child shall continue while the plan remains in force and the child remains in such condition, provided proof of such handicap is received by the carrier within thirty-one days of the date on which the child’s coverage would have terminated in the absence of such incapacity. The carrier may require subsequent proof of the child’s continued incapacity and dependency but not more often than once a year thereafter, or (ii) for the periods set forth for such child under federal extension requirements established by the Consolidated Omnibus Budget Reconciliation Act of 1985, P.L. 99-272, as amended from time to time; (B) as to the employee’s spouse, at the end of the month following the month in which a divorce, court-ordered annulment or legal separation is obtained, whichever is earlier, except that the plan shall provide the option for said spouse to continue coverage for the periods set forth for such events under federal extension requirements established by the Consolidated Omnibus Budget Reconciliation Act of 1985, P.L. 99-272, as amended from time to time; and (C) as to the employee or dependent who is sixty-five years of age or older, as of midnight of the day preceding such person’s eligibility for benefits under Title XVIII of the federal Social Security Act;

(6) As to any other event listed as a “qualifying event” in 29 USC 1163, as amended from time to time, continuation of coverage for such periods set forth for such event in 29 USC 1162, as amended from time to time, provided such plan may require the individual whose coverage is to be continued to pay up to the percentage of the applicable premium as specified for such event in 29 USC 1162, as amended from time to time.

Any continuation of coverage required by this section except subdivision (4) or (6) of this subsection may be subject to the requirement, on the part of the individual whose coverage is to be continued, that such individual contribute that portion of the premium the individual would have been required to contribute had the employee remained an active covered employee, except that the individual may be required to pay up to one hundred two per cent of the entire premium at the group rate if coverage is continued in accordance with subdivision (1), (2) or (5) of this subsection. The employer shall not be legally obligated by sections 38a-505, 38a-546 and 38a-551 to 38a-559, inclusive, to pay such premium if not paid timely by the employee.

(c) The commissioner shall adopt regulations, in accordance with chapter 54, concerning coordination of benefits between the plan and other health insurance plans. No individual or group health insurance plan shall coordinate benefits or otherwise reduce benefit payments because a person is covered by or receives benefits from a group specified disease policy delivered, issued for delivery, renewed, amended or continued in this state.

(d) The plan shall make available to Connecticut residents, in addition to any other conversion privilege available, a conversion privilege under which coverage shall be available immediately upon termination of coverage under the group plan. The terms and benefits offered under the conversion benefits shall be at least equal to the terms and benefits of an individual comprehensive health care plan.

(e) (1) The provisions of subdivision (1) of subsection (b) of this section shall apply to any individual for whom such continuation of coverage is in effect or who elects continuation of coverage pursuant to this section, on or after May 5, 2010.

(2) Each insurer and health care center that has issued a group health insurance policy subject to sections 38a-546 and 38a-554 shall, in conjunction with their group policyholders, including employers with fewer than twenty employees, provide notice of the continuation of coverage period specified in subdivision (1) of subsection (b) of this section to such individuals set forth in subdivision (1) of this subsection not later than sixty days after May 5, 2010.

(P.A. 75-616, S. 4, 12; P.A. 76-399, S. 1, 5; P.A. 86-106, S. 2; P.A. 87-274, S. 2; P.A. 97-268, S. 2; P.A. 02-55, S. 1; P.A. 03-77, S. 1; P.A. 07-185, S. 17; June Sp. Sess. P.A. 07-2, S. 65, 69; P.A. 08-147, S. 9; 08-181, S. 7; P.A. 09-124, S. 2; P.A. 10-13, S. 2.)

History: P.A. 76-399 allowed continuation of coverage to the thirty-ninth week following date of eligibility loss, rather than the ninetieth day following such date in Subsec. (b)(1) and (2); P.A. 86-106 amended Subsec. (b) to provide that if a dependent child is suffering from any mental handicap, rather than only mental retardation, on the date his coverage would otherwise be terminated, the coverage may be continued, and to limit the termination of coverage of those eligible for Medicare to those persons who are 65 years of age or older; P.A. 87-274 amended Subsec. (b) to increase extension rights upon the loss of employment from 39 to 78 weeks, and upon the death of the employee from 39 to 156 weeks; Sec. 38-374 transferred to Sec. 38a-554 in 1991; P.A. 97-268 deleted reference to low, middle and high option deductibles, amended Subsec. (a)(2) to make spouse a dependent for purposes of section, amended Subsec. (b)(1) and (2) to add disqualification based on an employee’s gross misconduct and to delete references to eligibility for periods of weeks and replace with references to federal COBRA, amended Subsec. (b)(5) to add choice for covered child by adding designators (i) and (ii) and allowing child and spouse to opt to continue coverage for periods provided under federal COBRA, and added court-ordered re annulment, added new Subdiv. (6) re other qualifying events, amended Subdiv. (7) to add reference to Subdiv. (6), to add reference to 102% of the entire premium and to add reference to Subdiv. (2) or (5) and made technical changes; P.A. 02-55 amended Subsec. (b)(3) to add “regardless of the employee’s or dependent’s eligibility for other group insurance” re an absence due to illness or injury, amended Subsec. (b)(4) to add “regardless of an individual’s eligibility for other group insurance” re coverage for totally disabled individuals upon termination of the group plan, and made technical changes in Subsecs. (b) and (c); P.A. 03-77 amended Subsec. (b)(1) to add exception re continuation of coverage if reduction of hours, leave of absence or termination of employment results from eligibility to receive Social Security income; P.A. 07-185 amended Subsecs. (a) and (b) by making a child eligible for coverage under a parent’s group comprehensive health care plan as long as the child remains unmarried and is under the age of 26 and residing in the state, effective July 1, 2007; June Sp. Sess. P.A. 07-2 changed effective date of P.A. 07-185, S. 17 to January 1, 2009, effective June 26, 2007, and made provisions allowing children to continue coverage until age 26 contingent upon children remaining state residents, except for full-time attendance at an out-of-state accredited institution of higher education or residency with a custodial parent pursuant to a child custody determination, effective January 1, 2009; P.A. 08-147 amended Subsec. (a) by deleting state residency requirement and amended Subsec. (b) by making technical changes and revising conditions upon which coverage of a child terminates by adding provision re coverage under a group health plan through a dependent child’s own employment, deleting custodial parent provision, and specifying that dependent children to age 19 are exempt from state residency requirement, effective January 1, 2009; P.A. 08-181 amended Subsec. (c) by prohibiting coordination of benefits or reduction in benefit payments because a person is covered by or receives benefits from a group specified disease policy in this state, effective June 12, 2008; P.A. 09-124 added requirement that a stepchild be covered on the same basis as a biological child in Subsec. (a), effective June 18, 2009; P.A. 10-13 amended Subsec. (b)(1) to replace provision re periods under federal COBRA with provision re period of 30 months after date of layoff, reduction of hours, leave of absence or termination of employment, made technical changes in Subsec. (b) and added Subsec. (e) re applicability of and notice requirement for Subsec. (b)(1), effective May 5, 2010.

See Sec. 31-51o re continuation of coverage in the event of a relocation or closing of a covered establishment.

See Sec. 38a-549 re adopted children.

Sec. 38a-555. (Formerly Sec. 38-375). Additional requirements for individual comprehensive health care plans. Carrier obligations concerning termination of coverage. An individual comprehensive health care plan shall contain the minimum standard benefits prescribed in section 38a-553, including the choice of the low option, middle option or high option deductible, and shall also conform in substance to the requirements of this section. Each individual comprehensive health care plan shall contain provisions: (1) Which obligate the carrier to continue the contract until the earlier of (A) the date on which the individual in whose name the contract was issued first becomes eligible for coverage under Title XVIII of the Social Security Act, provided the individual is sixty-five years of age or older, or under a group comprehensive health care plan, or (B) the plan anniversary date at least sixty days prior to which the carrier has mailed to the individual at his last address shown on the carrier’s records written notice of its decision not to continue coverage on a class basis only, or (C) the date on which the individual becomes eligible for coverage under a health insurance high risk pool or arrangement established by statute or regulation in another state. The carrier may reserve the right to adjust premiums by classes in accordance with its experience for policies or contracts not written by or through the Health Reinsurance Association, provided such premium may not exceed the premium established for that particular class by the Health Reinsurance Association; (2) which, upon the death of the individual in whose name the contract was issued, permits every other individual then covered under the contract to elect, within such period as shall be specified in the contract, to continue the same coverage until such time as he would have ceased to be entitled to coverage had the individual in whose name the contract was issued lived; and (3) under which the benefits payable shall be excess to all other sources of health insurance benefits, including benefits provided pursuant to any state or federal law other than Medicaid.

(P.A. 75-616, S. 5, 12; P.A. 86-106, S. 3; P.A. 91-100, S. 2.)

History: P.A. 86-106 limited the coverage termination provisions for persons eligible for Medicare to those persons over 65 years of age; Sec. 38-375 transferred to 38a-555 in 1991; P.A. 91-100 added Subdiv. (1)(C) to expand the carrier obligations re termination of coverage requirements for an individual comprehensive health care plan to include a provision detailing when an individual becomes eligible for coverage under a health insurance high risk pool or some other arrangement established by statute or regulation of another state.

Sec. 38a-556. (Formerly Sec. 38-376). Health Reinsurance Association. Classes of risk. Audits. Insurance Commissioner’s powers. Qualification as an acceptable alternative mechanism. There is hereby created a nonprofit legal entity to be known as the Health Reinsurance Association. All insurers, health care centers and self-insurers doing business in the state, as a condition to their authority to transact the applicable kinds of health insurance defined in section 38a-551, shall be members of the association. The association shall perform its functions under a plan of operation established and approved under subsection (a) of this section, and shall exercise its powers through a board of directors established under this section.

(a) (1) The board of directors of the association shall be made up of nine individuals selected by participating members, subject to approval by the commissioner, two of whom shall be appointed by the commissioner on or before July 1, 1993, to represent health care centers. To select the initial board of directors, and to initially organize the association, the commissioner shall give notice to all members of the time and place of the organizational meeting. In determining voting rights at the organizational meeting each member shall be entitled to vote in person or proxy. The vote shall be a weighted vote based upon the net health insurance premium derived from this state in the previous calendar year. If the board of directors is not selected within sixty days after notice of the organizational meeting, the commissioner may appoint the initial board. In approving or selecting members of the board, the commissioner may consider, among other things, whether all members are fairly represented. Members of the board may be reimbursed from the moneys of the association for expenses incurred by them as members, but shall not otherwise be compensated by the association for their services. (2) The board shall submit to the commissioner a plan of operation for the association necessary or suitable to assure the fair, reasonable and equitable administration of the association. The plan of operation shall become effective upon approval in writing by the commissioner consistent with the date on which the coverage under sections 38a-505, 38a-546 and 38a-551 to 38a-559, inclusive, must be made available. The commissioner shall, after notice and hearing, approve the plan of operation provided such plan is determined to be suitable to assure the fair, reasonable and equitable administration of the association, and provides for the sharing of association gains or losses on an equitable proportionate basis. If the board fails to submit a suitable plan of operation within one hundred eighty days after its appointment, or if at any time thereafter the board fails to submit suitable amendments to the plan, the commissioner shall, after notice and hearing, adopt and promulgate such reasonable rules as are necessary or advisable to effectuate the provisions of this section. Such rules shall continue in force until modified by the commissioner or superseded by a plan submitted by the board and approved by the commissioner. The plan of operation shall, in addition to requirements enumerated in sections 38a-505, 38a-546 and 38a-551 to 38a-559, inclusive: (A) Establish procedures for the handling and accounting of assets and moneys of the association; (B) establish regular times and places for meetings of the board of directors; (C) establish procedures for records to be kept of all financial transactions, and for the annual fiscal reporting to the commissioner; (D) establish procedures whereby selections for the board of directors shall be made and submitted to the commissioner; (E) establish procedures to amend, subject to the approval of the commissioner, the plan of operations; (F) establish procedures for the selection of an administrator and set forth the powers and duties of the administrator; (G) contain additional provisions necessary or proper for the execution of the powers and duties of the association; (H) establish procedures for the advertisement on behalf of all participating carriers of the general availability of the comprehensive coverage under sections 38a-505, 38a-546 and 38a-551 to 38a-559, inclusive; (I) contain additional provisions necessary for the association to qualify as an acceptable alternative mechanism in accordance with Section 2744 of the Public Health Service Act, as set forth in the Health Insurance Portability and Accountability Act of 1996, P.L. 104-191; and (J) contain additional provisions necessary for the association to qualify as acceptable coverage in accordance with the Pension Benefit Guaranty Corporation and Trade Adjustment Assistance programs of the Trade Act of 2002, P.L. 107-210. The commissioner may adopt regulations, in accordance with the provisions of chapter 54, to establish criteria for the association to qualify as an acceptable alternative mechanism.

(b) The association shall have the general powers and authority granted under the laws of this state to carriers to transact the kinds of insurance defined under section 38a-551, and in addition thereto, the specific authority to: (1) Enter into contracts necessary or proper to carry out the provisions and purposes of sections 38a-505, 38a-546 and 38a-551 to 38a-559, inclusive; (2) sue or be sued, including taking any legal actions necessary or proper for recovery of any assessments for, on behalf of, or against participating members; (3) take such legal action as necessary to avoid the payment of improper claims against the association or the coverage provided by or through the association; (4) establish, with respect to health insurance provided by or on behalf of the association, appropriate rates, scales of rates, rate classifications and rating adjustments, such rates not to be unreasonable in relation to the coverage provided and the operational expenses of the association; (5) administer any type of reinsurance program, for or on behalf of participating members; (6) pool risks among participating members; (7) issue policies of insurance on an indemnity or provision of service basis providing the coverage required by sections 38a-505, 38a-546 and 38a-551 to 38a-559, inclusive, in its own name or on behalf of participating members; (8) administer separate pools, separate accounts or other plans as deemed appropriate for separate members or groups of members; (9) operate and administer any combination of plans, pools, reinsurance arrangements or other mechanisms as deemed appropriate to best accomplish the fair and equitable operation of the association; (10) set limits on the amounts of reinsurance that may be ceded to the association by its members; (11) appoint from among participating members appropriate legal, actuarial and other committees as necessary to provide technical assistance in the operation of the association, policy and other contract design, and any other function within the authority of the association; and (12) apply for and accept grants, gifts and bequests of funds from other states, federal and interstate agencies and independent authorities, private firms, individuals and foundations for the purpose of carrying out its responsibilities. Any such funds received shall be deposited in the General Fund and shall be credited to a separate nonlapsing account within the General Fund for the Health Reinsurance Association and may be used by the Health Reinsurance Association in the performance of its duties.

(c) Every member shall participate in the association in accordance with the provisions of this subsection. (1) A participating member shall determine the particular risks it elects to have written by or through the association. A member shall designate which of the following classes of risks it shall underwrite in the state, from which classes of risk it may elect to reinsure selected risks: (A) Individual, excluding group conversion; and (B) individual, including group conversion. (2) No member shall be permitted to select out individual lives from an employer group to be insured by or through the association. Members electing to administer risks that are insured by or through the association shall comply with the benefit determination guidelines and the accounting procedures established by the association. A risk insured by or through the association cannot be withdrawn by the participating member except in accordance with the rules established by the association. (3) Rates for coverage issued by or through the association shall not be excessive, inadequate or unfairly discriminatory. Separate scales of premium rates based on age shall apply, but rates shall not be adjusted for area variations in provider costs. Premium rates shall take into consideration the substantial extra morbidity and administrative expenses for association risks, reimbursement or reasonable expenses incurred for the writing of association risks and the level of rates charged by insurers for groups of ten lives, provided incurred losses that result from provision of coverage in accordance with section 38a-537 shall not be considered. In no event shall the rate for a given classification or group be less than one hundred twenty-five per cent or more than one hundred fifty per cent of the average rate charged for that classification with similar characteristics under a policy covering ten lives. All rates shall be promulgated by the association through an actuarial committee consisting of five persons who are members of the American Academy of Actuaries, shall be filed with the commissioner and may be disapproved within sixty days from the filing thereof if excessive, inadequate or unfairly discriminatory.

(d) (1) Following the close of each fiscal year, the administrator shall determine the net premiums, reinsurance premiums less administrative expense allowance, the expense of administration pertaining to the reinsurance operations of the association and the incurred losses for the year. Any net loss shall be assessed to all participating members in proportion to their respective shares of the total health insurance premiums earned in this state during the calendar year, or with paid losses in the year, coinciding with or ending during the fiscal year of the association or on any other equitable basis as may be provided in the plan of operations. For self-insured members of the association, health insurance premiums earned shall be established by dividing the amount of paid health losses for the applicable period by eighty-five per cent. Net gains, if any, shall be held at interest to offset future losses or allocated to reduce future premiums. (2) Any net loss to the association represented by the excess of its actual expenses of administering policies issued by the association over the applicable expense allowance shall be separately assessed to those participating members who do not elect to administer their plans. All assessments shall be on an equitable formula established by the board. (3) The association shall conduct periodic audits to assure the general accuracy of the financial data submitted to the association and the association shall have an annual audit of its operations by an independent certified public accountant. The annual audit shall be filed with the commissioner for his review and the association shall be subject to the provisions of section 38a-14. (4) For the fiscal year ending December 31, 1993, and the first quarter of the fiscal year ending December 31, 1994, the administrator shall not include health care centers in assessing any net losses to participating members.

(e) All policy forms issued by or through the association shall conform in substance to prototype forms developed by the association, shall in all other respects conform to the requirements of sections 38a-505, 38a-546 and 38a-551 to 38a-559, inclusive, and shall be approved by the commissioner. The commissioner may disapprove any such form if it contains a provision or provisions which are unfair or deceptive or which encourage misrepresentation of the policy.

(f) Unless otherwise permitted by the plan of operation, the association shall not issue, reissue or continue in force comprehensive health care plan coverage with respect to any person who is already covered under an individual or group comprehensive health care plan, or who is sixty-five years of age or older and eligible for Medicare or who is not a resident of this state. Coverage provided to a HIPAA or health care tax credit eligible individual may be terminated to the extent permitted by HIPAA or the Trade Act of 2002, respectively.

(g) Benefits payable under a comprehensive health care plan insured by or reinsured through the association shall be paid net of all other health insurance benefits paid or payable through any other source, and net of all health insurance coverages provided by or pursuant to any other state or federal law including Title XVIII of the Social Security Act, Medicare, but excluding Medicaid.

(h) There shall be no liability on the part of and no cause of action of any nature shall arise against any carrier or its agents or its employees, the Health Reinsurance Association or its agents or its employees or the residual market mechanism established under the provisions of section 38a-557 or its agents or its employees, or the commissioner or his representatives for any action taken by them in the performance of their duties under sections 38a-505, 38a-546 and 38a-551 to 38a-559, inclusive. This provision shall not apply to the obligations of a carrier, a self-insurer, the Health Reinsurance Association or the residual market mechanism for payment of benefits provided under a comprehensive health care plan.

(P.A. 75-616, S. 6, 12; P.A. 82-159, S. 2; P.A. 86-106, S. 4; P.A. 90-134, S. 25, 28; P.A. 93-338, S. 3; June 18 Sp. Sess. P.A. 97-8, S. 69, 70, 88; June 30 Sp. Sess. P.A. 03-6, S. 68; P.A. 04-10, S. 10, 11; 04-257, S. 63; P.A. 10-5, S. 33; P.A. 12-145, S. 22.)

History: P.A. 82-159 amended Subsec. (c) exempting losses resulting from retroactive coverage under Sec. 38-262c from consideration in determining premium rates; P.A. 86-106 amended Subsec. (f) to provide that no coverage shall be provided any individual who is both eligible for Medicare and 65 years of age or older; P.A. 90-134 removed language in Subsec. (c) re groups of between 3 and 25 employees or members; Sec. 38-376 transferred to Sec. 38a-556 in 1991; P.A. 93-338 expanded the scope of the Health Reinsurance Association to include “health care centers”, increased membership of the board of directors of the Health Reinsurance Association from seven to nine, adding two representatives of health care centers and added new Subsec. (d)(4) excluding health care centers in assessing net losses for the fiscal year ending December 31, 1993, and the first quarter of the fiscal year ending December 31, 1994; June 18 Sp. Sess. P.A. 97-8 added Subsec. (a)(I) re provisions necessary for the association to qualify as an acceptable alternative mechanism and amended Subsec. (f) re termination of coverage for a HIPAA eligible individual, effective July 1, 1997; June 30 Sp. Sess. P.A. 03-6 made a technical change, added Subsec. (a)(2)(J) re inclusion of provisions necessary for association to qualify as acceptable coverage in accordance with the Pension Benefit Guaranty Corporation and Trade Adjustment Assistance programs of the Trade Act of 2002, added Subsec. (b)(12) re application for and acceptance of grants for carrying out responsibilities and amended Subsec. (f) to include termination of coverage to health care tax credit eligible individuals and add reference to the Trade Act of 2002, effective August 20, 2003; P.A. 04-10 added “as” in Subsec. (b)(3) and substituted “substance” for “substances” in Subsec. (e); P.A. 04-257 made technical changes in Subsec. (c), effective June 14, 2004; P.A. 10-5 made technical changes, effective May 5, 2010; P.A. 12-145 made a technical change, effective June 15, 2012.

Sec. 38a-556a. Connecticut Clearinghouse. (a) There is established a program which shall be known as the “Connecticut Clearinghouse”, to be administered by the Health Reinsurance Association established in section 38a-556, through which individuals and small employers may obtain information about available health insurance policies and health care plans.

(b) Said association shall, in consultation with the Insurance Commissioner and the Healthcare Advocate, develop, within available appropriations, a web site, telephone number or other method to serve as a clearinghouse for information about individual and small employer health insurance policies and health care plans that are available to consumers in this state, including, but not limited to, the Medicaid program, the HUSKY Plan, the Charter Oak Health Plan set forth in section 17b-311, the Municipal Employee Health Insurance Plan set forth in subsection (i) of section 5-259, and any individual or small employer health insurance policies or health care plans an insurer, health care center or other entity chooses to list with the Connecticut Clearinghouse.

(c) Such method developed pursuant to subsection (b) of this section shall use interactive tools or technology to provide a consumer with a list of health insurance policies or health care plans that, based on the responses provided by such consumer, may be appropriate for such consumer’s circumstances.

(d) The Insurance Commissioner shall establish procedures for the Health Reinsurance Association to confirm with the Insurance Department that a policy or plan listed with the Connecticut Clearinghouse is approved to be sold in this state and that the insurer, health care center or other entity that offers such policy or plan is authorized to do business in this state. Such procedures shall include, but not be limited to, a timetable for such list to be updated on a regular basis, but not less than every ninety days.

(P.A. 10-4, S. 3; P.A. 11-44, S. 138.)

History: P.A. 10-4 effective July 1, 2010; P.A. 11-44 amended Subsec. (b) by deleting “state-administered general assistance”, effective July 1, 2011.

Sec. 38a-557. (Formerly Sec. 38-377). Hospital and medical service corporations. Residual market mechanism. Insurance Commissioner’s powers concerning such mechanisms. (a) Hospital service corporations and medical service corporations may elect to meet the obligations of section 38a-552 by participating in the Health Reinsurance Association established in section 38a-556, as a full member thereof, or by making comprehensive health care plans available directly through a subscriber contract or combination of contracts or by forming a separate residual market mechanism substantially similar to the association established in section 38a-556.

(b) In the event that hospital service corporations and medical service corporations choose to form a separate residual market mechanism, the commissioner shall have the same regulatory powers over that residual market mechanism as the commissioner has over the Health Reinsurance Association, and such residual market mechanism shall have the same powers and duties as the association. Rating classifications under a residual market mechanism established under this section need not be the same as classifications established under the association, but any rates established by the residual market mechanism shall be approved by the commissioner. The commissioner shall promulgate regulations to carry out the requirements of this section.

(c) If hospital service corporations and medical service corporations do not elect to participate in the Health Reinsurance Association, such service corporations shall be required to make an individual comprehensive health care plan available to every resident of this state except residents who are both sixty-five years of age or older and eligible for Medicare and whose coverage under a group or individual contract issued by such service corporations has terminated. Such coverage may be made available through a separate residual market mechanism established under this section.

(P.A. 75-616, S. 7, 12; P.A. 76-435, S. 23, 82; P.A. 86-106, S. 5; P.A. 12-145, S. 23.)

History: P.A. 76-435 included reference to terminated individual contracts issued by hospital or medical service corporation in Subsec. (c); P.A. 86-106 limited in Subsec. (c) the exemption from the required availability of individual comprehensive health care plans to those residents of this state who are at least 65 years of age and eligible for Medicare; Sec. 38-377 transferred to Sec. 38a-557 in 1991; P.A. 12-145 made technical changes, effective June 15, 2012.

Sec. 38a-558. (Formerly Sec. 38-380). Office of Health Care Access. In addition to the powers and duties already granted to it by law, the Office of Health Care Access shall, within one year of April 1, 1976, adopt regulations designed to allow state professional standard review organizations established under U.S. Public Law 92-603 to extend its review of certain inpatient services to services received by all patients. Such regulations shall be adopted in accordance with the provisions of chapter 54.

(P.A. 75-616, S. 10, 12; P.A. 77-118; P.A. 95-257, S. 39, 58.)

History: P.A. 77-118 substituted “allow” for “require” and P.L. 92-603 for P.L. 92-403; however because of an oversight or computer input error these changes were not made in the general statutes until the 1985 revision; Sec. 38-380 transferred to Sec. 38a-558 in 1991; P.A. 95-257 replaced Commission on Hospitals and Health Care with Office of Health Care Access, effective July 1, 1995.

Sec. 38a-559. (Formerly Sec. 38-381). Commissioner of Social Services. Contract authority concerning Medicaid programs. The Commissioner of Social Services may enter into contractual agreements with any carrier or with the Health Reinsurance Association or a residual market mechanism to obtain appropriate administrative services, insurance benefits or any other insurance related services in connection with the state’s Medicaid program. All terms and provisions of any such contracts shall be mutually acceptable to the parties involved.

(P.A. 75-420, S. 4, 6; 75-616, S. 11, 12; P.A. 77-614, S. 521, 587, 608, 610; P.A. 78-303, S. 85, 136; P.A. 93-262, S. 1, 87.)

History: P.A. 75-420 allowed substitution of commissioner of social services for welfare commissioner in the public act which created the section (P.A. 75-616); P.A. 77-614 and P.A. 78-303 replaced commissioner of social services with commissioner of income maintenance, effective January 1, 1979; Sec. 38-381 transferred to Sec. 38a-559 in 1991; P.A. 93-262 authorized substitution of commissioner and department of social services for commissioner and department of income maintenance, effective July 1, 1993.

Secs. 38a-560. Small employer grouping for health insurance coverage. Small employers, as defined in section 38a-564, may group together solely for the purpose of securing group health insurance coverage.

(P.A. 93-69.)

Secs. 38a-561 to 38a-563. Reserved for future use.

PART V

BLUE RIBBON HEALTH CARE PLANS

Sec. 38a-564. Definitions. As used in this section and sections 12-201, 12-211, 12-212a and 38a-565 to 38a-572, inclusive:

(1) “Pool” means the Connecticut Small Employer Health Reinsurance Pool, established under section 38a-569.

(2) “Board” means the board of directors of the pool.

(3) “Eligible employee” means an employee who works a normal work week of twenty or more hours and includes a sole proprietor, a partner of a partnership or an independent contractor, provided such sole proprietor, partner or contractor is included as an employee under a health care plan of a small employer but does not include an employee who works on a seasonal, temporary or substitute basis. “Eligible employee” shall include any employee who is not actively at work but is covered under the small employer’s health insurance plan pursuant to (A) workers’ compensation, (B) continuation of benefits pursuant to section 38a-554, or (C) other applicable laws.

(4) (A) “Small employer” means any person, firm, corporation, limited liability company, partnership or association actively engaged in business or self-employed for at least three consecutive months who, on at least fifty per cent of its working days during the preceding twelve months, employed no more than fifty eligible employees, the majority of whom were employed within the state of Connecticut. “Small employer” includes a self-employed individual. For the purposes of determining the number of eligible employees under this subdivision: (i) Companies that are affiliated companies, as defined in section 33-840, or that are eligible to file a combined tax return for purposes of taxation under chapter 208 shall be considered one employer; (ii) employees covered through the employer by health insurance plans or insurance arrangements issued to or in accordance with a trust established pursuant to collective bargaining subject to the federal Labor Management Relations Act shall not be counted; (iii) employees who are not actively at work but are covered under the small employer’s health insurance plan pursuant to workers’ compensation, continuation of benefits pursuant to section 38a-554 or other applicable laws shall not be counted; and (iv) employees who work a normal work week of less than thirty hours shall not be counted. Except as otherwise specifically provided, provisions of this section and sections 12-201, 12-211, 12-212a and 38a-565 to 38a-572, inclusive, that apply to a small employer shall continue to apply until the plan anniversary following the date the employer no longer meets the requirements of this definition.

(B) “Small employer” does not include (i) a municipality procuring health insurance pursuant to section 5-259, (ii) a private school in this state procuring health insurance through a health insurance plan or an insurance arrangement sponsored by an association of such private schools, (iii) a nonprofit organization procuring health insurance pursuant to section 5-259, unless the Secretary of the Office of Policy and Management and the State Comptroller make a request in writing to the Insurance Commissioner that such nonprofit organization be deemed a small employer for the purposes of this chapter, (iv) an association for personal care assistants procuring health insurance pursuant to section 5-259, or (v) a community action agency procuring health insurance pursuant to section 5-259.

(5) “Insurer” means any insurance company, hospital or medical service corporation, or health care center, authorized to transact health insurance business in this state.

(6) “Insurance arrangement” means any multiple employer welfare arrangement, as defined in Section 3 of the Employee Retirement Income Security Act of 1974 (ERISA), as amended from time to time, except for any such arrangement that is fully insured within the meaning of Section 514(b)(6) of said act, as amended from time to time.

(7) “Health insurance plan” means any hospital and medical expense incurred policy, hospital or medical service plan contract and health care center subscriber contract and does not include (A) accident only, credit, dental, vision, Medicare supplement, long-term care or disability insurance, hospital indemnity coverage, coverage issued as a supplement to liability insurance, insurance arising out of a workers’ compensation or similar law, automobile medical-payments insurance, or insurance under which beneficiaries are payable without regard to fault and which is statutorily required to be contained in any liability insurance policy or equivalent self-insurance, or (B) policies of specified disease or limited benefit health insurance, provided that the carrier offering such policies files on or before March first of each year a certification with the commissioner that contains the following: (i) A statement from the carrier certifying that such policies are being offered and marketed as supplemental health insurance and not as a substitute for hospital or medical expense insurance; (ii) a summary description of each such policy including the average annual premium rates, or range of premium rates in cases where premiums vary by age, gender or other factors, charged for such policies in the state; and (iii) in the case of a policy that is described in this subparagraph and that is offered for the first time in this state on or after October 1, 1993, the carrier files with the commissioner the information and statement required in this subparagraph at least thirty days prior to the date such policy is issued or delivered in this state.

(8) “Plan of operation” means the plan of operation of the pool, including articles, bylaws and operating rules, adopted by the board pursuant to section 38a-569.

(9) “Late enrollee” means an eligible employee or dependent who requests enrollment in a small employer’s health insurance plan following the initial enrollment period provided under the terms of the first plan for which such employee or dependent was eligible through such small employer, provided an eligible employee or dependent shall not be considered a late enrollee if (A) the request for enrollment is made within thirty days after termination of coverage provided under another group health insurance plan and if the individual had not initially requested coverage under such plan solely because he was covered under another group health insurance plan and coverage under that plan has ceased due to termination of employment, death of a spouse, or divorce, or due to that plan’s involuntary termination or cancellation by its carrier for reasons other than nonpayment of premium, or (B) the individual is employed by an employer who offers multiple health insurance plans and the individual elects a different health insurance plan during an open enrollment period, or (C) a court has ordered coverage be provided for a spouse or minor child under a covered employee’s plan and request for enrollment is made within thirty days after issuance of such court order, or (D) if the request for enrollment is made within thirty days after the marriage of such employee or the birth or adoption of the first child by such employee after the later of the commencement of the employer’s plan or the date the pool becomes operational, and satisfactory evidence of such marriage, birth or adoption is provided to the small employer carrier.

(10) “Department” means the Insurance Department.

(11) “Special health care plan” means a health insurance plan for previously uninsured small employers, established by the board in accordance with section 38a-565 or by the Health Reinsurance Association in accordance with section 38a-570.

(12) “Small employer health care plan” means a health insurance plan for small employers, established by the board in accordance with section 38a-568.

(13) “Dependent” means the spouse or child of an eligible employee, subject to applicable terms of the health insurance plan covering such employee. “Dependent” shall also include any dependent that is covered under the small employer’s health insurance plan pursuant to workers’ compensation, continuation of benefits pursuant to section 38a-554 or other applicable laws.

(14) “Commissioner” means the Insurance Commissioner.

(15) “Member” means each insurer and insurance arrangement participating in the pool.

(16) “Small employer carrier” means any insurer or insurance arrangement which offers or maintains group health insurance plans covering eligible employees of one or more small employers.

(17) “Preexisting conditions provision” means a policy provision that excludes coverage for charges or expenses incurred during a specified period following the insured’s effective date of coverage as to a condition that, during a specified period immediately preceding the effective date of coverage, had manifested itself in such a manner as would cause an ordinary prudent person to seek diagnosis, care or treatment or for which medical advice, diagnosis, care or treatment was recommended or received as to that condition.

(18) “Base premium rate” means, as to any health insurance plan or insurance arrangement covering one or more employees of a small employer, the lowest new business premium rate charged by the insurer or insurance arrangement for the same or similar coverage which is equivalent in value under a plan or arrangement covering any small employer with similar case characteristics, other than claim experience, as determined by such insurer or insurance arrangement, except that as to any small employer carrier or insurance arrangement not issuing new health insurance plans or insurance arrangements to a small employer, “base premium rate” means the lowest rate charged a small employer for the same or similar coverage which is equivalent in value, under a plan or arrangement covering any small employer with similar case characteristics, other than claim experience, as determined by such insurer or insurance arrangement.

(19) “Low-income eligible employee” means an eligible employee of a small employer whose annualized wages from such small employer determined as of the effective date of the special health care plan or as of any anniversary of such effective date as certified to the insurer or insurance arrangement or the Health Reinsurance Association, as the case may be, by such small employer is less than three hundred per cent of the federal poverty level applicable to such person.

(20) “Medicare” means the Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965, as amended from time to time.

(21) “Health Reinsurance Association” means the entity established and maintained in accordance with the provisions of sections 38a-505, 38a-546 and 38a-551 to 38a-559, inclusive.

(22) “Reimbursement rate” means, as to individuals covered under special health care plans or an individual special health care plan, seventy-five per cent of the Medicare reimbursement rate for benefits normally reimbursable under Medicare. For services or supplies not reimbursed by Medicare, such reimbursement shall be seventy-five per cent of the amount which would be payable under Medicare, if Medicare was responsible for benefit payments under such plans for such services and supplies, as determined by the board and approved by the commissioner.

(23) “Individual special health care plan” means a health insurance plan for individuals, issued by the Health Reinsurance Association in accordance with section 38a-571 or issued by an insurer in accordance with section 38a-565.

(24) “Low-income individual” means an individual whose adjusted gross income (AGI) for the individual and spouse, from the most recent federal tax return filed prior to the date of application for the individual special health care plan or prior to any anniversary of the effective date of the plan, as certified by such individual, is less than three hundred per cent of the applicable federal poverty level.

(25) “Medicare reimbursement rate” means the amount which would be payable under Medicare for benefits normally reimbursed under Medicare.

(26) “Health care center” means health care center as defined in section 38a-175.

(27) “Case characteristics” means demographic or other objective characteristics of a small employer, including age, sex, family composition, location, size of group, administrative cost savings resulting from the administration of an association group plan or a plan written pursuant to section 5-259 and industry classification, as determined by a small employer carrier, that are considered by the small employer carrier in the determination of premium rates for the small employer. Claim experience, health status, and duration of coverage since issue are not case characteristics for the purpose of sections 38a-564 to 38a-572, inclusive.

(28) “Actuarial certification” means a written statement by a member of the American Academy of Actuaries or other individual acceptable to the commissioner that a small employer carrier is in compliance with the provisions of subdivisions (4), (6), (7) and (9) of section 38a-567 and the regulations promulgated by the commissioner pursuant to section 38a-567, based upon the person’s examination, including a review of the appropriate records and of the actuarial assumptions and methods used by the small employer carrier in establishing premium rates for applicable health benefit plans.

(P.A. 90-134, S. 12, 28; P.A. 91-201, S. 4, 8; P.A. 92-125, S. 1, 5; P.A. 93-137, S. 1, 6; 93-239, S. 9; 93-345, S. 6; P.A. 94-214, S. 2, 4; P.A. 95-79, S. 144, 189; P.A. 96-271, S. 213, 254; P.A. 99-124, S. 1, 4; P.A. 00-114, S. 1, 2; 00-218, S. 1; P.A. 01-30, S. 2, 4; June 30 Sp. Sess. P.A. 03-3, S. 32; P.A. 04-163, S. 1; P.A. 05-238, S. 3; P.A. 07-185, S. 18, 19; P.A. 08-110, S. 3; P.A. 10-4, S. 1; 10-5, S. 34; 10-13, S. 4; P.A. 11-19, S. 14; 11-58, S. 46.)

History: P.A. 91-201 redefined “small employer” to account for Taft-Hartley trust plans, clarified the definition of “late enrollee” for purposes of enrolling in a small employer health plan, and redefined “small employer carrier” to include maintenance of insurance plans, amended the definition of “base premium rate” to address small employer carriers not issuing new coverage and added a definition of “case characteristic”; P.A. 92-125 amended Subdiv. (9) to add provision concerning involuntary termination or cancellation, Subdiv. (24) to change annualized wages from all employers to the adjusted gross income from the most recent federal tax return filed prior to the date of application and added Subdiv. (28) to define “actuarial certification”; P.A. 93-137 redefined “eligible employee” to conditionally include any employee who is not actively at work but is covered under an employer’s health insurance plan, redefined “small employer” to require that the employer has been in business for at least 3 consecutive months during the preceding 12 months and redefined “dependent” to include any dependent who is covered under an employer health insurance plan, effective June 11, 1993; P.A. 93-239 corrected internal references in definition of “pool”; P.A. 93-345 added Subdiv. (7)(B) re policies of specified disease or limited health benefit and made technical changes; P.A. 94-214 amended the definition of “small employer” by increasing the number of eligible employees to qualify as a small employer from 25 to 50, effective July 1, 1994; P.A. 95-79 redefined “small employer” to include a limited liability company, effective May 31, 1995; P.A. 96-271 amended definition of “small employer” to replace reference to Sec. 33-374a with Sec. 33-840, effective January 1, 1997; P.A. 99-124 amended Subdiv. (4) to provide that “small employer” does not include a municipality procuring health insurance pursuant to Sec. 5-259, effective July 1, 1999; P.A. 00-114 amended definition of “small employer” in Subdiv. (4) to insert Subpara. (A) designator re municipalities and add new language as Subpara. (B) to exempt a private school procuring health insurance through an insurance arrangement or association of private schools, effective May 26, 2000; P.A. 00-218 redefined “small employer” in Subdiv. (4) to include persons self-employed for at least 3 consecutive months, and to state that “small employer includes a self-employed individual”; P.A. 01-30 added Subdiv. (4)(C) excluding certain nonprofit organizations from the definition of “small employer”, effective July 1, 2001; June 30 Sp. Sess. P.A. 03-3 added Subdiv. (4)(D) excluding an association for personal care assistants procuring health insurance pursuant to Sec. 5-259 from definition of “small employer”, effective August 20, 2003; P.A. 04-163 redefined “case characteristics” in Subdiv. (27) to include administrative cost savings, effective July 1, 2004; P.A. 05-238 amended Subdiv. (4) to redefine “small employer” by inserting Subpara. designators (A) and (B), redesignating existing Subparas. (A) to (D) as Subpara. (B)(i) to (iv) and adding Subpara. (B)(v) re community action agencies, effective July 8, 2005; P.A. 07-185 amended Subdiv. (19) to redefine “low-income eligible employee” as one whose annualized wages are less than 300% of the federal poverty level and amended Subdiv. (24) to redefine “low-income individual” as one whose adjusted gross income for the individual and spouse is less than 300% of the applicable federal poverty level, effective July 1, 2007; P.A. 08-110 made a technical change in Subdiv. (4)(A), effective May 27, 2008; P.A. 10-4 amended Subdiv. (3) to redefine “eligible employee” and amended Subdiv. (4) to redefine “small employer”, effective January 1, 2011; P.A. 10-5 made technical changes in Subdivs. (3) and (4)(A), effective May 5, 2010; P.A. 10-13 amended Subdiv. (3) to redefine “eligible employee”, amended Subdiv. (4) to redefine “small employer”, amended Subdiv. (13) to redefine “dependent” and made technical changes, effective May 5, 2010; P.A. 11-19 made technical changes; P.A. 11-58 redefined “preexisting conditions provision” in Subdiv. (17), effective July 2, 2011.

Sec. 38a-565. Special health care plans. (a)(1) In order to facilitate the provision of lower cost health insurance coverage for uninsured small employers, the board shall establish, subject to the approval of the commissioner, special health care plans for use by the Health Reinsurance Association. The board shall submit such plans to the commissioner for the commissioner’s approval. The board shall take into consideration the levels of health care plans provided in Connecticut and such medical and economic factors as may be deemed appropriate and shall establish benefit levels, deductibles, coinsurance factors, maximum copayment obligations and exclusions and limitations which the board considers appropriate for uninsured small employers, provided the level of reimbursement shall be based on the reimbursement rate. Such plans may include cost containment features such as, but not limited to: (A) Preferred provider provisions; (B) utilization review of health care services, including review of medical necessity of hospital and physician services; (C) case management benefit alternatives; and (D) other managed care provisions.

(2) After the commissioner’s approval of special health care plans submitted by the board pursuant to subdivision (1) of this subsection, and in lieu of the procedure established by section 38a-481, the Health Reinsurance Association may certify to the commissioner, in the form and manner prescribed by the commissioner, that the special health care plans filed by said association are in substantial compliance with the provisions in the corresponding approved board plan. Upon receipt by the department of such certification, said association may offer such certified plans until such time as the commissioner, after notice and hearing, disapproves their continued use.

(b) (1) Not later than ninety days after approval by the commissioner of the special health care plans submitted by the board, the Health Reinsurance Association shall offer small employers such plans. Except as provided in subdivision (2) of this subsection, every small employer that elects to be covered under a special health care plan and agrees to make the required premium payments and to satisfy the other provisions of the plan shall be issued such a plan by the Health Reinsurance Association.

(2) No small employer shall be eligible to purchase a special health care plan unless such employer had maintained no health insurance coverage for its employees at any time during the one-year period ending on the date of application for such policy. No small employer shall purchase a special health care plan for more than three years.

(c) Insurers may issue individual special health care plans subject to the laws applicable to individual health insurance in this state, provided such policies shall be identical to the individual special health care plans made available by the Health Reinsurance Association pursuant to section 38a-571.

(P.A. 90-134, S. 13, 28; P.A. 91-201, S. 6, 8; P.A. 93-137, S. 2, 6; 93-239, S. 6; P.A. 07-185, S. 20; P.A. 08-33, S. 1.)

History: P.A. 91-201 added Subsec. (b)(6) setting conditions under which small employer carriers are not required to offer small employer coverage; P.A. 93-137 amended Subsec. (b) to require small employer carriers who do not offer special health care plans to refer small employers to the Health Reinsurance Association and reduced the period during which an employer must have not carried coverage for its employees from two years to one year to purchase special health care plans, effective June 11, 1993; P.A. 93-239 corrected an internal reference in Subsec. (a)(2); P.A. 07-185 deleted former Subsec. (b)(3) re sale of special health care plans with initial effective date of January 1, 1995, or later and redesignated existing Subsec. (b)(4) to (6) as Subsec. (b)(3) to (5), effective July 1, 2007; P.A. 08-33 made technical changes, amended Subsecs. (a) and (b) to delete references to special health care plans from small employer carriers and health care centers and, in Subsec. (b), deleted former Subdivs. (3) to (5) re special health care plans offered by small employer carriers and health care centers, effective May 7, 2008.

Sec. 38a-566. Health insurance plans or insurance arrangements covering employees of a small employer. Trusts. Trade associations. Self-employed individuals. (a) Any individual or group health insurance plan or any insurance arrangement shall be subject to the provisions of sections 12-201, 12-211, 12-212a and 38a-564 to 38a-572, inclusive, if it provides health insurance or is an insurance arrangement covering one or more employees of a small employer and if any one of the following conditions are met:

(1) Any portion of the premium or benefits is paid by a small employer or any covered individual is reimbursed, whether through wage adjustments or otherwise, by a small employer for any portion of the premium; or

(2) The health insurance plan or arrangement is treated by the employer or any of the covered individuals as part of a plan or program for the purposes of Section 162 or Section 106 of the United States Internal Revenue Code.

(b) Nothing in this section shall be construed to apply the provisions of sections 12-202 and 12-212a to health care centers.

(c) Notwithstanding the provisions of subsection (a) of this section, health insurance plans or insurance arrangements issued to or in accordance with a trust established pursuant to collective bargaining, subject to the federal Labor Management Relations Act and which cover, in the aggregate, more than twenty-five employees of all participating employers, shall not be subject to the provisions of section 38a-567 or subparagraph (A) of subdivision (2) of subsection (e) of section 38a-569 and insurers or insurance arrangements issuing only such plans shall not be considered small employer carriers for purposes of sections 38a-565 and 38a-568.

(d) A small employer carrier that ceases marketing to small employers as provided in subsection (d) of section 38a-568 shall not cease enrolling new employers in a policy issued to provide coverage to the members of a trade association or to a trust on behalf of a trade association if the following conditions exist:

(1) Such trade association is a not-for-profit trade association qualified under 26 USC Section 501c(6), was not formed solely for the purpose of providing insurance and has been operating continuously for at least twenty-five years.

(2) The policy issued to or on behalf of such association was in existence prior to June 1, 1990, and has annual premiums of less than twenty-five million dollars.

(3) Such policy is offered on a guaranteed issue basis to all small employer members and only to members of such trade association.

(e) Subsection (a) of this section shall not apply to an individual health insurance plan issued to a self-employed individual if the carrier discloses on the application and marketing materials, in not less than ten-point type, the following notice: “THIS PLAN IS ISSUED ON AN INDIVIDUAL BASIS AND IS REGULATED AS AN INDIVIDUAL HEALTH INSURANCE PLAN.”

(P.A. 90-134, S. 17, 28; P.A. 91-201, S. 3, 8; P.A. 92-125, S. 2, 5; P.A. 98-122; P.A. 08-33, S. 4.)

History: P.A. 91-201 added Subsec. (c) to account for Taft-Hartley trust plans; P.A. 92-125 added Subsec. (d) concerning coverage to members of trade associations and trusts on behalf of a trade association; P.A. 98-122 substituted “construed” for “interpreted” in Subsec. (b) and added new Subsec. (e) re self-employed individuals; P.A. 08-33 made technical changes and changed “may” to “shall” in Subsec. (d), effective May 7, 2008.

Sec. 38a-567. Provisions of small employer plans and arrangements. Health insurance plans and insurance arrangements covering small employers and insurers and producers marketing such plans and arrangements shall be subject to the following provisions:

(1) (A) (i) Any such insurer or producer marketing such plans or arrangements shall offer premium quotes to small employers upon request for coverage for employees who work a normal work week of thirty or more hours. Upon request by a small employer, such insurer or producer shall offer premium quotes for coverage for employees that include those who work a normal work week of at least twenty hours.

(ii) No small employer that has requested premium quotes for coverage for employees that include those who work a normal work week of less than thirty hours shall be required to accept such quotes or coverage in lieu of premium quotes or coverage for only those employees who work a normal work week of thirty or more hours.

(iii) Nothing in this subparagraph shall require a small employer that offers coverage to its employees who work a normal work week of thirty hours or more to offer coverage to its employees who work a normal work week of less than thirty hours.

(B) Any such plan or arrangement shall be renewable with respect to all eligible employees or dependents at the option of the small employer, policyholder or contractholder, as the case may be, except: (i) For nonpayment of the required premiums by the small employer, policyholder or contractholder; (ii) for fraud or misrepresentation of the small employer, policyholder or contractholder or, with respect to coverage of individual insured, the insureds or their representatives; (iii) for noncompliance with plan or arrangement provisions; (iv) when the number of insureds covered under the plan or arrangement is less than the number of insureds or percentage of insureds required by participation requirements under the plan or arrangement; or (v) when the small employer, policyholder or contractholder is no longer actively engaged in the business in which it was engaged on the effective date of the plan or arrangement.

(C) Renewability of coverage may be effected by either continuing in effect a plan or arrangement covering a small employer or by substituting upon renewal for the prior plan or arrangement the plan or arrangement then offered by the carrier that most closely corresponds to the prior plan or arrangement and is available to other small employers. Such substitution shall only be made under conditions approved by the commissioner. A carrier may substitute a plan or arrangement as stated above only if the carrier effects the same substitution upon renewal for all small employers previously covered under the particular plan or arrangement, unless otherwise approved by the commissioner. The substitute plan or arrangement shall be subject to the rating restrictions specified in this section on the same basis as if no substitution had occurred, except for an adjustment based on coverage differences.

(D) Notwithstanding the provisions of this subdivision, any such plan or arrangement, or any coverage provided under such plan or arrangement may be rescinded for fraud, intentional material misrepresentation or concealment by an applicant, employee, dependent or small employer.

(E) Any individual who was not a late enrollee at the time of his or her enrollment and whose coverage is subsequently rescinded shall be allowed to reenroll as of a current date in such plan or arrangement subject to any preexisting condition or other provisions applicable to new enrollees without previous coverage. On and after the effective date of such individual’s reenrollment, the small employer carrier may modify the premium rates charged to the small employer for the balance of the current rating period and for future rating periods, to the level determined by the carrier as applicable under the carrier’s established rating practices had full, accurate and timely underwriting information been supplied when such individual initially enrolled in the plan. The increase in premium rates allowed by this provision for the balance of the current rating period shall not exceed twenty-five per cent of the small employer’s current premium rates. Any such increase for the balance of said current rating period shall not be subject to the rate limitation specified in subdivision (6) of this section. The rate limitation specified in this section shall otherwise be fully applicable for the current and future rating periods. The modification of premium rates allowed by this subdivision shall cease to be permitted for all plans and arrangements on the first rating period commencing on or after July 1, 1995.

(2) Except in the case of a late enrollee who has failed to provide evidence of insurability satisfactory to the insurer, the plan or arrangement may not exclude any eligible employee or dependent who would otherwise be covered under such plan or arrangement on the basis of an actual or expected health condition of such person. No plan or arrangement may exclude an eligible employee or eligible dependent who, on the day prior to the initial effective date of the plan or arrangement, was covered under the small employer’s prior health insurance plan or arrangement pursuant to workers’ compensation, continuation of benefits pursuant to section 38a-554 or other applicable laws. The employee or dependent must request coverage under the new plan or arrangement on a timely basis and such coverage shall terminate in accordance with the provisions of the applicable law.

(3) (A) For rating periods commencing on or after October 1, 1993, and prior to July 1, 1994, the premium rates charged or offered for a rating period for all plans and arrangements may not exceed one hundred thirty-five per cent of the base premium rate for all plans or arrangements.

(B) For rating periods commencing on or after July 1, 1994, and prior to July 1, 1995, the premium rates charged or offered for a rating period for all plans or arrangements may not exceed one hundred twenty per cent of the base premium rate for such rating period. The provisions of this subdivision shall not apply to any small employer who employs more than twenty-five eligible employees.

(4) For rating periods commencing on or after October 1, 1993, and prior to July 1, 1995, the percentage increase in the premium rate charged to a small employer, who employs not more than twenty-five eligible employees, for a new rating period may not exceed the sum of:

(A) The percentage change in the base premium rate measured from the first day of the prior rating period to the first day of the new rating period;

(B) An adjustment of the small employer’s premium rates for the prior rating period, and adjusted pro rata for rating periods of less than one year, due to the claim experience, health status or duration of coverage of the employees or dependents of the small employer, such adjustment (i) not to exceed ten per cent annually for the rating periods commencing on or after October 1, 1993, and prior to July 1, 1994, and (ii) not to exceed five per cent annually for the rating periods commencing on or after July 1, 1994, and prior to July 1, 1995; and

(C) Any adjustments due to change in coverage or change in the case characteristics of the small employer, as determined from the small employer carrier’s applicable rate manual.

(5) (A) With respect to plans or arrangements issued on or after July 1, 1995, the premium rates charged or offered to small employers shall be established on the basis of a community rate, adjusted to reflect one or more of the following classifications:

(i) Age, provided age brackets of less than five years shall not be utilized;

(ii) Gender;

(iii) Geographic area, provided an area smaller than a county shall not be utilized;

(iv) Industry, provided the rate factor associated with any industry classification shall not vary from the arithmetic average of the highest and lowest rate factors associated with all industry classifications by greater than fifteen per cent of such average, and provided further, the rate factors associated with any industry shall not be increased by more than five per cent per year;

(v) Group size, provided the highest rate factor associated with group size shall not vary from the lowest rate factor associated with group size by a ratio of greater than 1.25 to 1.0;

(vi) Administrative cost savings resulting from the administration of an association group plan or a plan written pursuant to section 5-259, provided the savings reflect a reduction to the small employer carrier’s overall retention that is measurable and specifically realized on items such as marketing, billing or claims paying functions taken on directly by the plan administrator or association, except that such savings may not reflect a reduction realized on commissions;

(vii) Savings resulting from a reduction in the profit of a carrier who writes small business plans or arrangements for an association group plan or a plan written pursuant to section 5-259 provided any loss in overall revenue due to a reduction in profit is not shifted to other small employers; and

(viii) Family composition, provided the small employer carrier shall utilize only one or more of the following billing classifications: (I) Employee; (II) employee plus family; (III) employee and spouse; (IV) employee and child; (V) employee plus one dependent; and (VI) employee plus two or more dependents.

(B) The small employer carrier shall quote premium rates to small employers after receipt of all demographic rating classifications of the small employer group. No small employer carrier may inquire regarding health status or claims experience of the small employer or its employees or dependents prior to the quoting of a premium rate.

(C) The provisions of subparagraphs (A) and (B) of this subdivision shall apply to plans or arrangements issued on or after July 1, 1995. The provisions of subparagraphs (A) and (B) of this subdivision shall apply to plans or arrangements issued prior to July 1, 1995, as of the date of the first rating period commencing on or after that date, but no later than July 1, 1996.

(6) For any small employer plan or arrangement on which the premium rates for employee and dependent coverage or both, vary among employees, such variations shall be based solely on age and other demographic factors permitted under subparagraph (A) of subdivision (5) of this section and such variations may not be based on health status, claim experience, or duration of coverage of specific enrollees. Except as otherwise provided in subdivision (1) of this section, any adjustment in premium rates charged for a small employer plan or arrangement to reflect changes in case characteristics prior to the end of a rating period shall not include any adjustment to reflect the health status, medical history or medical underwriting classification of any new enrollee for whom coverage begins during the rating period.

(7) For rating periods commencing prior to July 1, 1995, in any case where a small employer carrier utilized industry classification as a case characteristic in establishing premium rates, the rate factor associated with any industry classification shall not vary from the arithmetical average of the highest and lowest rate factors associated with all industry classifications by greater than fifteen per cent of such average.

(8) Differences in base premium rates charged for health benefit plans by a small employer carrier shall be reasonable and reflect objective differences in plan design, not including differences due to the nature of the groups assumed to select particular health benefit plans.

(9) For rating periods commencing prior to July 1, 1995, in any case where an insurer issues or offers a policy or contract under which premium rates for a specific small employer are established or adjusted in part based upon the actual or expected variation in claim costs or actual or expected variation in health conditions of the employees or dependents of such small employer, the insurer shall make reasonable disclosure of such rating practices in solicitation and sales materials utilized with respect to such policy or contract.

(10) If a small employer carrier denies coverage as requested to a small employer that is self-employed, the small employer carrier shall promptly offer such small employer the opportunity to purchase a small employer health care plan. If a small employer carrier or any producer representing that carrier fails, for any reason, to offer coverage as requested by a small employer that is self-employed, that small employer carrier shall promptly offer such small employer an opportunity to purchase a small employer health care plan.

(11) No small employer carrier or producer shall, directly or indirectly, engage in the following activities:

(A) Encouraging or directing small employers to refrain from filing an application for coverage with the small employer carrier because of the health status, claims experience, industry, occupation or geographic location of the small employer, except the provisions of this subparagraph shall not apply to information provided by a small employer carrier or producer to a small employer regarding the carrier’s established geographic service area or a restricted network provision of a small employer carrier; or

(B) Encouraging or directing small employers to seek coverage from another carrier because of the health status, claims experience, industry, occupation or geographic location of the small employer.

(12) No small employer carrier shall, directly or indirectly, enter into any contract, agreement or arrangement with a producer that provides for or results in the compensation paid to a producer for the sale of a health benefit plan to be varied because of the health status, claims experience, industry, occupation or geographic area of the small employer. A small employer carrier shall provide reasonable compensation, as provided under the plan of operation of the program, to a producer, if any, for the sale of a special or a small employer health care plan. No small employer carrier shall terminate, fail to renew or limit its contract or agreement of representation with a producer for any reason related to the health status, claims experience, occupation, or geographic location of the small employers placed by the producer with the small employer carrier.

(13) No small employer carrier or producer shall induce or otherwise encourage a small employer to separate or otherwise exclude an employee from health coverage or benefits provided in connection with the employee’s employment.

(14) Denial by a small employer carrier of an application for coverage from a small employer shall be in writing and shall state the reasons for the denial.

(15) No small employer carrier or producer shall disclose (A) to a small employer the fact that any or all of the eligible employees of such small employer have been or will be reinsured with the pool, or (B) to any eligible employee or dependent the fact that he has been or will be reinsured with the pool.

(16) If a small employer carrier enters into a contract, agreement or other arrangement with another party to provide administrative, marketing or other services related to the offering of health benefit plans to small employers in this state, the other party shall be subject to the provisions of this section.

(17) The commissioner may adopt regulations in accordance with the provisions of chapter 54 setting forth additional standards to provide for the fair marketing and broad availability of health benefit plans to small employers.

(18) Each small employer carrier shall maintain at its principal place of business a complete and detailed description of its rating practices and renewal underwriting practices, including information and documentation that demonstrates that its rating methods and practices are based upon commonly accepted actuarial assumptions and are in accordance with sound actuarial principles. Each small employer carrier shall file with the commissioner annually, on or before March fifteenth, an actuarial certification certifying that the carrier is in compliance with this part and that the rating methods have been derived using recognized actuarial principles consistent with the provisions of sections 38a-564 to 38a-573, inclusive. Such certification shall be in a form and manner and shall contain such information as determined by the commissioner. A copy of the certification shall be retained by the small employer carrier at its principal place of business. Any information and documentation described in this subdivision but not subject to the filing requirement shall be made available to the commissioner upon his request. Except in cases of violations of sections 38a-564 to 38a-573, inclusive, the information shall be considered proprietary and trade secret information and shall not be subject to disclosure by the commissioner to persons outside of the department except as agreed to by the small employer carrier or as ordered by a court of competent jurisdiction.

(19) The commissioner may suspend all or any part of this section relating to the premium rates applicable to one or more small employers for one or more rating periods upon a filing by the small employer carrier and a finding by the commissioner that either the suspension is reasonable in light of the financial condition of the carrier or that the suspension would enhance the efficiency and fairness of the marketplace for small employer health insurance.

(20) For rating periods commencing prior to July 1, 1995, a small employer carrier shall quote premium rates to any small employer within thirty days after receipt by the carrier of such employer’s completed application.

(21) Any violation of subdivisions (10) to (16), inclusive, of this section and of any regulations established under subdivision (17) of this section shall be an unfair and prohibited practice under sections 38a-815 to 38a-830, inclusive.

(22) (A) With respect to plans or arrangements issued pursuant to subsection (i) of section 5-259, at the option of the Comptroller, the premium rates charged or offered to small employers purchasing health insurance shall not be subject to this section, provided (i) the plan or plans offered or issued cover such small employers as a single entity and cover not less than three thousand employees on the date issued, (ii) each small employer is charged or offered the same premium rate with respect to each employee and dependent, and (iii) the plan or plans are written on a guaranteed issue basis.

(B) With respect to plans or arrangements issued by an association group plan, at the option of the administrator of the association group plan, the premium rates charged or offered to small employers purchasing health insurance shall not be subject to this section, provided (i) the plan or plans offered or issued cover such small employers as a single entity and cover not less than three thousand employees on the date issued, (ii) each small employer is charged or offered the same premium rate with respect to each employee and dependent, and (iii) the plan or plans are written on a guaranteed issue basis. In addition, such association group (I) shall be a bona fide group as set forth in the Employee Retirement and Security Act of 1974, (II) shall not be formed for the purposes of fictitious grouping, as defined in section 38a-827, and (III) shall not issue any plan that shall cause undue disruption in the insurance marketplace, as determined by the commissioner.

(P.A. 90-134, S. 18, 28; P.A. 91-201, S. 2, 8; P.A. 92-125, S. 3, 5; P.A. 93-137, S. 3, 6; 93-345, S. 4; P.A. 94-214, S. 3, 4; P.A. 96-193, S. 14, 36; P.A. 99-59, S. 1; P.A. 04-163, S. 2; P.A. 05-238, S. 4, 5; P.A. 08-33, S. 2, 3; 08-181, S. 3; P.A. 10-4, S. 2; 10-13, S. 5; P.A. 11-19, S. 15; 11-58, S. 48.)

History: P.A. 91-201 clarified the renewability provisions concerning small employer plans and the insurer’s right to rescind coverage based on fraud or misrepresentation and eliminating an insurance carrier’s ability to pass through reinsurance premiums; P.A. 92-125 made numerous changes and additions concerning renewability of coverage when a product line is discontinued, conditions under which reenrollment is permitted when coverage is rescinded for fraud, limits on range in rates, differences in plan design used for premium rates for plans, liberalizing of preexisting condition credits, reducing the maximum allowable percentage increase in rates and establishing requirements for fair marketing of health benefit plans; P.A. 93-137 applied provisions to insurers, agents and brokers marketing small employer health plans and arrangements, amended Subdiv. (4) to disallow exclusion for those employees or dependents previously covered under a prior small employer health plan issued pursuant to workers’ compensation or COBRA who request such coverage on a timely basis, inserted a new Subdiv. (17) re disclosure to a small employer or employee or dependent concerning reinsurance of covered persons with pool, made technical changes for statutory consistency, renumbered the remaining Subdivs. and amended internal references, effective June 11, 1993; P.A. 93-345 deleted Subdivs. (1) and (2) re preexisting condition coverage, Subdiv. (5) re maximum allowable premium rate charged, Subdivs. (6) and (7) re increase in premium rates for rating periods prior to October 1, 1992, amended Subdiv. (1)(D) re application of modification of premium rates not permitted after July 1, 1995, inserted new Subdiv. (3) re caps on premiums for rating periods October 1, 1993 to June 30, 1994, and from July 1, 1994, to July 1, 1995, amended Subdiv. (4) to change October 1, 1992, to October 1, 1993, and added prior to July 1, 1995, deleted 15% annual adjustment and inserted 10% and 5% for October 1, 1993, to June 30, 1994, and July 1, 1994, to July 1, 1995 rating period respectively, added new Subdiv. (5) re adjusted community rating, added new Subdiv. (19) re time for quotation and made technical changes; P.A. 94-214 amended Subdiv. (3) to specify its inapplicability to any small employers who employ more than 25 eligible employees and amended Subdiv. (4) to specify applicability of maximum increase in the premium rate charged to a small employer who employs not more than 25 eligible employees, effective July 1, 1994; P.A. 96-193 substituted “producer” for “agent” and “broker”, effective June 3, 1996; P.A. 99-59 amended Subdiv. (21) to substitute “38a-830” for “38a-831”; P.A. 04-163 inserted new Subdiv. (5)(A)(vi) to include administrative cost savings as a community rating classification, renumbered existing Subdiv. (5)(A)(vi) as Subdiv. (5)(A)(vii) and amended same to change subclause designators (a) to (f), inclusive, to (I) to (VI), inclusive, effective July 1, 2004; P.A. 05-238 inserted new Subdiv. (5)(A)(vii) re savings resulting from a reduction in profit, and redesignated existing Subdiv. (5)(A)(vii) as Subdiv. (5)(A)(viii) and added new Subdiv. (22) re premium rates of plans or arrangements under Sec. 5-259 and association group plans that are not subject to section, effective July 8, 2005; P.A. 08-33 amended Subdiv. (10) to make technical changes, add “that is self-employed” re small employer and delete references to special health care plans from small employer carriers, and amended Subdiv. (18) to make a technical change, effective May 7, 2008; P.A. 08-181 amended Subdiv. (22) by designating existing provisions as Subpara. (A), making conforming changes therein, deleting references to association group plan and reducing number of covered lives required from 10,000 eligible individuals to 3,000 employees, and by adding Subpara. (B) re association group plans; P.A. 10-4 amended Subdiv. (1) to add new Subpara. (A) re premium quotes for small employers and redesignate existing Subparas. (A) to (D) as Subparas. (B) to (E), effective January 1, 2011; P.A. 10-13 amended Subdiv. (2) to change reference re continuation of coverage from federal COBRA to Sec. 38a-554, and made technical changes in Subdiv. (21), effective May 5, 2010; P.A. 11-19 made a technical change in Subdiv. (18); P.A. 11-58 inserted “intentional” re misrepresentation or concealment in Subdiv. (1)(D), effective July 2, 2011.

Sec. 38a-568. Coverage under small employer health care plans and arrangements. Approval by commissioner. (a)(1) Subject to approval by the commissioner, the board shall establish the form and level of coverages to be made available by small employer carriers in accordance with the provisions of subsection (b) of this section. Such coverages, which shall be designated as small employer health care plans, shall be limited to: (A) A basic hospital plan, (B) a basic surgical plan, (C) major medical plans which can be written in conjunction with basic hospital plans or basic surgical plans, (D) comprehensive plans, and (E) plans with benefit and cost-sharing levels which are consistent with the basic method of operation and the benefit plans of health care centers, including any restrictions imposed by federal law. The board shall submit such plans to the commissioner for the commissioner’s approval not later than ninety days after the appointment of the board pursuant to section 38a-569. The board shall take into consideration the levels of health insurance provided in Connecticut and such medical and economic factors as may be deemed appropriate and shall establish benefit levels, deductibles, coinsurance factors, exclusions and limitations determined to be generally reflective of health insurance provided to small employers. Such plans may include cost containment features including, but not limited to: (i) Preferred provider provisions; (ii) utilization review of health care services, including review of medical necessity of hospital and physician services; (iii) case management benefit alternatives; and (iv) other managed care provisions.

(2) After the commissioner’s approval of small employer health care plans submitted by the board pursuant to subdivision (1) of this subsection, and in lieu of the procedure established by section 38a-513, any small employer carrier may certify to the commissioner, in the form and manner prescribed by the commissioner, that the small employer health care plans filed by the carrier are in substantial compliance with the provisions in the corresponding approved board plan. Upon receipt by the department of such certification, the carrier may use such certified plans until such time as the commissioner, after notice and hearing, disapproves their continued use.

(b) Not later than ninety days after the commissioner’s approval of small employer health care plans submitted by the board, each small employer carrier, including, but not limited to, each health care center, shall, as a condition of transacting such insurance in this state, offer those small employer health care plans that correspond to the insurance products being currently offered by the carrier to small employers. Each small employer that elects to be covered under such plan and agrees to make the required premium payments and to satisfy the other provisions of the plan shall be issued such a plan by the small employer carrier.

(c) No health care center shall be required to offer coverage or accept applications pursuant to subsection (b) of this section in the case of any of the following: (1) To a group, where the group is not physically located in the health care center’s approved service area; (2) to an employee, where the employee does not work or reside within the health care center’s approved service area; (3) within an area, where the health care center reasonably anticipates, and demonstrates to the satisfaction of the commissioner, that it will not have the capacity within that area in its network of providers to deliver services adequately to the members of such groups because of its obligations to existing group contract holders and enrollees; (4) where the commissioner finds that acceptance of an application or applications would place the health care center in an impaired financial condition; or (5) where the commissioner finds that compliance with subsection (b) or (f) of this section would place the health care center in an impaired financial condition. A health care center that refuses to offer coverage pursuant to subdivision (3) of this subsection may not, for ninety days after such refusal, offer coverage in the applicable area to new cases of employer groups with more than twenty-five eligible employees.

(d) A small employer carrier shall not be required to offer coverage or accept applications pursuant to subsection (b) of this section subject to the following conditions: (1) The small employer carrier ceases to market health insurance or health benefit plans to small employers and ceases to enroll small employers under existing health insurance or health benefit plans; (2) the small employer carrier notifies the commissioner of its decision to cease marketing to small employers and to cease enrolling small employers, as provided in subdivision (1) of this subsection; and (3) the small employer carrier is prohibited from reentering the small employer market for a period of five years from the date of the notice required under subdivision (2) of this subsection.

(e) For groups containing only one member, a small employer carrier or health care center offering coverage pursuant to this section may require proof that the individual has been self-employed for three consecutive months.

(f) Each small employer carrier, including, but not limited to, a health care center, shall offer each health care plan that the carrier makes available to small employers, except association group plans, to all small employers, including, but not limited to, groups containing only one member.

(P.A. 90-134, S. 19, 28; P.A. 91-201, S. 7, 8; P.A. 93-137, S. 4, 6; 93-239, S. 7; P.A. 00-218, S. 2; P.A. 01-174, S. 3, 4.)

History: P.A. 91-201 added Subsec. (d) setting conditions under which small employer carriers can stop offering small employer coverage; P.A. 93-137 made technical changes for statutory accuracy, effective June 11, 1993; P.A. 93-239 corrected an internal reference in Subsec. (a)(2); P.A. 00-218 amended Subsecs. (a) and (b) to substitute “the commissioner’s” for “his”, “not later than” for “within”, “including” for “such as” and “that” for “which”, deleted Subsec. (c)(5) exception allowing health care centers to refuse to offer coverage to groups of fewer than three eligible employees, and added new Subsec. (e) re proof of self-employment for groups containing only one member; P.A. 01-174 amended Subsec. (b) to add “including, but not limited to, each health care center” re small employer carriers, and substituted “each” for “every”, and added Subsec. (c)(5) re commissioner’s finding re compliance with Subsec. (b) or (f) and added Subsec. (f) re offer of health care plans, except association group plans, to all small employers.

Sec. 38a-569. Connecticut Small Employer Health Reinsurance Pool. (a)(1) There is established a nonprofit entity to be known as the “Connecticut Small Employer Health Reinsurance Pool”. All insurers issuing health insurance in this state and insurance arrangements providing health plan benefits in this state on and after July 1, 1990, shall be members of the pool.

(2) On or before July 15, 1990, the commissioner shall give notice to all insurers and insurance arrangements of the time and place for the initial organizational meeting, which shall take place by September 1, 1990. The members shall select the initial board, subject to approval by the commissioner. The board shall consist of at least five and not more than nine representatives of members. There shall be no more than two members of the board representing any one insurer or insurance arrangement. In determining voting rights at the organizational meeting, each member shall be entitled to vote in person or by proxy. The vote shall be weighted based upon net health insurance premium derived from this state in the previous calendar year. To the extent possible, at least one-third of the members of the board shall be domestic insurance companies and at least two-thirds of the members of the board shall be small employer carriers. At least one member of the board shall be a health care center and at least one member shall be a small employer carrier with less than one hundred million dollars in net small employer health insurance premium in this state. The Insurance Commissioner shall be an ex-officio member of the board. The net premium amount shall be adjusted by the board periodically for health care cost inflation. In approving selection of the board, the commissioner shall assure that all members are fairly represented. The membership of all boards subsequent to the initial board shall, to the extent possible, reflect the same distribution of representation as is described in this subdivision.

(3) If the initial board is not elected at the organizational meeting, the commissioner shall appoint the initial board within fifteen days of the organizational meeting.

(4) Within ninety days after the appointment of such initial board, the board shall submit to the commissioner a plan of operation and thereafter any amendments thereto necessary or suitable to assure the fair, reasonable and equitable administration of the pool. The commissioner shall, after notice and hearing, approve the plan of operation provided he determines it to be suitable to assure the fair, reasonable and equitable administration of the pool, and provides for the sharing of pool gains or losses on an equitable proportionate basis in accordance with the provisions of subsection (d) of this section. The plan of operation shall become effective upon approval in writing by the commissioner consistent with the date on which the coverage under this section shall be made available. If the board fails to submit a suitable plan of operation within one hundred eighty days after its appointment, or at any time thereafter fails to submit suitable amendments to the plan of operation, the commissioner shall, after notice and hearing, adopt and promulgate a plan of operation or amendments, as appropriate. The commissioner shall amend any plan adopted by him, as necessary, at the time a plan of operation is submitted by the board and approved by the commissioner.

(5) The plan of operation shall establish procedures for: (A) Handling and accounting of assets and moneys of the pool, and for an annual fiscal reporting to the commissioner; (B) filling vacancies on the board, subject to the approval of the commissioner; (C) selecting an administrator and setting forth the powers and duties of the administrator; (D) reinsuring risks in accordance with the provisions of this section; (E) collecting assessments from all members to provide for claims reinsured by the pool and for administrative expenses incurred or estimated to be incurred during the period for which the assessment is made; and (F) any additional matters at the discretion of the board.

(6) The pool shall have the general powers and authority granted under the laws of Connecticut to insurance companies licensed to transact health insurance and, in addition thereto, the specific authority to: (A) Enter into contracts as are necessary or proper to carry out the provisions and purposes of this section, including the authority, with the approval of the commissioner, to enter into contracts with programs of other states for the joint performance of common functions, or with persons or other organizations for the performance of administrative functions; (B) sue or be sued, including taking any legal actions necessary or proper for recovery of any assessments for, on behalf of, or against members; (C) take such legal action as necessary to avoid the payment of improper claims against the pool; (D) define the array of health coverage products for which reinsurance will be provided, and to issue reinsurance policies, in accordance with the requirements of this section; (E) establish rules, conditions and procedures pertaining to the reinsurance of members’ risks by the pool; (F) establish appropriate rates, rate schedules, rate adjustments, rate classifications and any other actuarial functions appropriate to the operation of the pool; (G) assess members in accordance with the provisions of subsection (e) of this section, and to make advance interim assessments as may be reasonable and necessary for organizational and interim operating expenses. Any such interim assessments shall be credited as offsets against any regular assessments due following the close of the fiscal year; (H) appoint from among members appropriate legal, actuarial and other committees as necessary to provide technical assistance in the operation of the pool, policy and other contract design, and any other function within the authority of the pool; and (I) borrow money to effect the purposes of the pool. Any notes or other evidence of indebtedness of the pool not in default shall be legal investments for insurers and may be carried as admitted assets.

(b) Any member may reinsure with the pool coverage of an eligible employee of a small employer, or any dependent of such an employee, except that no member may reinsure with the pool coverage of an eligible employee of a small employer, or any dependent of such an employee, whose premium rates are not subject to section 38a-567 pursuant to subdivision (22) of section 38a-567. Any reinsurance placed with the pool from the date of the establishment of the pool regarding the coverage of an eligible employee of a small employer, or any dependent of such an employee shall be provided as follows:

(1) (A) With respect to a special health care plan or a small employer health care plan, the pool shall reinsure the level of coverage provided; (B) with respect to other plans, the pool shall reinsure the level of coverage provided up to, but not exceeding, the level of coverage provided in a small employer health care plan or the actuarial equivalent thereof as defined and authorized by the board; and (C) in either case, no reinsurance may be provided in any calendar year for a reinsured employee or dependent until five thousand dollars in benefit payments have been made for services provided during that calendar year for that reinsured employee or dependent, which payments would have been reimbursed through said reinsurance in the absence of the annual five-thousand-dollar deductible. The amount of the deductible shall be periodically reviewed by the board and may be adjusted for appropriate factors as determined by the board;

(2) With respect to eligible employees, and their dependents, coverage may be reinsured: (A) Within such period of time after the commencement of their coverage under the plan as may be authorized by the board, or (B) commencing January 1, 1992, on the first plan anniversary after the employer’s coverage has been in effect with the small employer carrier for a period of three years, and every third plan anniversary thereafter, provided, commencing May 1, 1994, reinsurance pursuant to this subparagraph shall only be permitted with respect to eligible employees and their dependents of a small employer which has no more than two eligible employees as of the applicable anniversary;

(3) Reinsurance coverage may be terminated for each reinsured employee or dependent on any plan anniversary;

(4) Reinsurance of newborn dependents shall be allowed only if the mother of any such dependent is reinsured as of the date of birth of such child, and all newborn dependents of reinsured persons shall be automatically reinsured as of their date of birth; and

(5) Notwithstanding the provisions of subparagraph (A) of subdivision (2) of this subsection: (A) Coverage for eligible employees and their dependents provided under a group policy covering two or more small employers shall not be eligible for reinsurance when such coverage is discontinued and replaced by a group policy of another carrier covering two or more small employers, unless coverage for such eligible employees or dependents was reinsured by the prior carrier; and (B) at the time coverage is assumed for such group by a succeeding carrier, such carrier shall notify the pool of its intention to provide coverage for such group and shall identify the employees and dependents whose coverage will continue to be reinsured. The time limitations for providing such notice shall be established by the pool.

(c) Except as provided in subsection (d) of this section, premium rates charged for reinsurance by the pool shall be established at the following percentages of the rate established by the pool for that classification or group with similar characteristics and coverage:

(1) One hundred fifty per cent, with respect to all of the eligible employees, and their dependents, of a small employer, all of whose coverage is reinsured in accordance with subdivision (2) of subsection (b) of this section; and

(2) Five hundred per cent, with respect to an eligible employee or dependent who is individually reinsured in accordance with subdivision (2) of subsection (b) of this section and is not reinsured with all eligible employees of an employer and their dependents.

(d) Premium rates charged for reinsurance by the pool to a health care center which is approved by the Secretary of Health and Human Services as a health maintenance organization pursuant to 42 USC 300 et seq., and as such is subject to requirements that limit the amount of risk that may be ceded to the pool, may be modified by the board, if appropriate, to reflect the portion of risk that may be ceded to the pool.

(e) (1) Following the close of each fiscal year, the administrator shall determine the net premiums, the pool expenses of administration and the incurred losses for the year, taking into account investment income and other appropriate gains and losses. For purposes of this section, health insurance premiums earned by insurance arrangements shall be established by adding paid health losses and administrative expenses of the insurance arrangement. Health insurance premiums and benefits paid by a member that are less than an amount determined by the board to justify the cost of collection shall not be considered for purposes of determining assessments. For purposes of this subsection, “net premiums” means health insurance premiums, less administrative expense allowances.

(2) Any net loss for the year shall be recouped by assessments of members. (A) Assessments shall first be apportioned by the board among all members in proportion to their respective shares of the total health insurance premiums earned in this state from health insurance plans and insurance arrangements covering small employers during the calendar year coinciding with or ending during the fiscal year of the pool, or on any other equitable basis reflecting coverage of small employers as may be provided in the plan of operations. An assessment shall be made pursuant to this subparagraph against a health care center, which is approved by the Secretary of Health and Human Services as a health maintenance organization pursuant to 42 USC 300e et seq., subject to an assessment adjustment formula adopted by the board and approved by the commissioner for such health care centers which recognizes the restrictions imposed on such health care centers by federal law. Such adjustment formula shall be adopted by the board and approved by the commissioner prior to the first anniversary of the pool’s operation. (B) If such net loss is not recouped before assessments totaling five per cent of such premiums from plans and arrangements covering small employers have been collected, additional assessments shall be apportioned by the board among all members in proportion to their respective shares of the total health insurance premiums earned in this state from other individual and group plans and arrangements, exclusive of any individual Medicare supplement policies as defined in section 38a-495 during such calendar year. (C) Notwithstanding the provisions of this subdivision, the assessments to any one member under subparagraph (A) or (B) of this subdivision shall not exceed forty per cent of the total assessment under each subparagraph for the first fiscal year of the pool’s operation and fifty per cent of the total assessment under each subparagraph for the second fiscal year. Any amounts abated pursuant to this subparagraph shall be assessed against the other members in a manner consistent with the basis for assessments set forth in this subdivision.

(3) If assessments exceed actual losses and administrative expenses of the pool, the excess shall be held at interest and used by the board to offset future losses or to reduce pool premiums. As used in this subsection, “future losses” includes reserves for incurred but not reported claims.

(4) Each member’s proportion of participation in the pool shall be determined annually by the board based on annual statements and other reports deemed necessary by the board and filed by the member with it. Insurance arrangements shall report to the board claims payments made and administrative expenses incurred in this state on an annual basis on a form prescribed by the commissioner.

(5) Provision shall be made in the plan of operation for the imposition of an interest penalty for late payment of assessments.

(6) The board may defer, in whole or in part, the assessment of a health care center if, in the opinion of the board: (A) Payment of the assessment would endanger the ability of the health care center to fulfill its contractual obligations, or (B) in accordance with standards included in the plan of operation, the health care center has written, and reinsured in their entirety, a disproportionate number of special health care plans. In the event an assessment against a health care center is deferred in whole or in part, the amount by which such assessment is deferred may be assessed against the other members in a manner consistent with the basis for assessments set forth in this subsection. The health care center receiving such deferment shall remain liable to the pool for the amount deferred. The board may attach appropriate conditions to any such deferment.

(f) (1) Neither the participation in the pool as members, the establishment of rates, forms or procedures nor any other joint or collective action required by this section shall be the basis of any legal action, criminal or civil liability or penalty against the pool or any of its members.

(2) Any person or member made a party to any action, suit or proceeding because the person or member served on the board or on a committee or was an officer or employee of the pool shall be held harmless and be indemnified by the program against all liability and costs, including the amounts of judgments, settlements, fines or penalties, and expenses and reasonable attorney’s fees incurred in connection with the action, suit or proceeding. The indemnification shall not be provided on any matter in which the person or member is finally adjudged in the action, suit or proceeding to have committed a breach of duty involving gross negligence, dishonesty, wilful misfeasance or reckless disregard of the responsibilities of office. Costs and expenses of the indemnification shall be prorated and paid for by all members. The Insurance Commissioner may retain actuarial consultants necessary to carry out said commissioner’s responsibilities pursuant to sections 38a-564 to 38a-572, inclusive, and such expenses shall be paid by the pool established in this section.

(P.A. 90-134, S. 20, 28; P.A. 91-201, S. 1, 8; P.A. 92-125, S. 4, 5; P.A. 93-137, S. 5, 6; 93-345, S. 5; P.A. 05-238, S. 6; P.A. 10-5, S. 35.)

History: P.A. 91-201 amended Subsec. (a) to clarify the requirement that the reinsurance pool board’s composition ensure fair representation, to require the board to determine whether reinsurance coverage can be deferred and to give approval to enter into contracts with programs of other states for the performance of common functions, amended Subsec. (b) to provide for an annual deductible of $5,000 on reinsurance per covered individual, to give the board discretion to determine when insurance coverage can be reinsured and to allow for reinsuring newborn infants, amended Subsecs. (c) and (d) to establish a more uniform reinsurance premium rate system, repealed Subsec. (e) re reinsurance premium and relettered (f) as (e) and (g) as (f) and made technical changes; P.A. 92-125 amended Subsec. (b) to permit use of the actuarial equivalent of small employer benefit plans in calculating reimbursement amount for reinsurance; P.A. 93-137 amended Subsec. (b)(2) to specify when reinsurance is allowed and added new Subsec. (b)(6) disallowing reinsurance for two or more small employers when such coverage is discontinued or replaced by a group policy of another carrier unless the coverage was reinsured by a previous carrier, effective June 11, 1993; P.A. 93-345 deleted Subsec. (b)(4) re determination by the board whether reinsurance can be deferred; P.A. 05-238 amended Subsec. (b) to exempt coverage for employees or dependents whose premium rates are not subject to Sec. 38a-567 and make technical changes, effective July 8, 2005; P.A. 10-5 made technical changes in Subsecs. (a)(5), (e)(1) and (f)(2), effective May 5, 2010.

Sec. 38a-570. Issuance of special health care plans by the Health Reinsurance Association to small employers. Notwithstanding the provisions of sections 38a-505, 38a-546 and 38a-551 to 38a-559, inclusive, the Health Reinsurance Association may issue special health care plans to small employers with ten or fewer eligible employees, the majority of whom are low-income eligible employees. The following provisions shall apply to such special health care plans:

(1) Premium rates shall be promulgated by the board of directors of the Health Reinsurance Association based on recommendations of its actuarial committee. In developing recommendations for premium rates, the actuarial committee shall consider, in addition to other pertinent matters, the premiums that are or would be charged for the same or similar insurance by other insurers. Except as otherwise provided in sections 38a-564 to 38a-572, inclusive, in establishing premium rates the board of directors of the Health Reinsurance Association may consider any relevant factors impacting premium, claims and expenses, including characteristics of small employers and insureds, that may be considered by any insurer in establishing health insurance premium rates. The premium rates established shall be subject to the provisions of section 38a-567. The anticipated loss ratio shall not be less than eighty per cent of the premium. In establishing premium rates the board of directors of the Health Reinsurance Association shall administer special health care plans issued to small employers without gain or loss; and

(2) The Health Reinsurance Association may reinsure coverage of special health care plans with the pool.

(P.A. 90-134, S. 21, 28; P.A. 07-185, S. 21.)

History: P.A. 07-185 amended Subdiv. (1) to require board of directors of Health Reinsurance Association to administer special health care plans issued to small employers without gain or loss, effective July 1, 2007.

Sec. 38a-571. Issuance of individual special health care plans by the Health Reinsurance Association. In addition to the options for individual comprehensive health care plans, the Health Reinsurance Association shall make available to individuals, on the same terms and conditions as are applicable to the other individual comprehensive health care plan options under sections 38a-505, 38a-546 and 38a-551 to 38a-559, inclusive, including the provisions for establishment and filing of premium rates, the option to purchase an individual special health care plan identical to the special health care plan for small employers established in accordance with section 38a-565. The requirement that coverage not have been maintained for a one-year period contained in subdivision (2) of subsection (b) of section 38a-565 shall not apply to individual special health care plans.

(P.A. 90-134, S. 22, 28; P.A. 08-33, S. 5.)

History: P.A. 08-33 made a technical change and changed “two-year” to “one-year” re period of coverage maintenance, effective May 7, 2008.

Sec. 38a-572. Requirement to provide service to certain low-income persons. No individual or organization that provides medical advice, diagnosis, care or treatment of a type covered under a special health care plan, as defined in section 38a-565 or 38a-570, shall, on or after July 1, 1990, provide such service to any person in this state unless such individual or organization provides such service, upon request, on the basis of the applicable reimbursement rate, to low-income eligible employees or their dependents covered under such special health care plans or low income individuals or their dependents covered under individual special health care plans, as defined in section 38a-571.

(P.A. 90-134, S. 23, 28; P.A. 08-33, S. 6.)

History: P.A. 08-33 made technical changes and added cites to Secs. 38a-565, 38a-570 and 38a-571, effective May 7, 2008.

Sec. 38a-573. Validity of separate provisions. If any provision of sections 38a-564 to 38a-572, inclusive, is held invalid, the invalidity shall not affect other provisions of said sections which can be given effect without the invalid provisions.

(P.A. 90-134, S. 27, 28.)

Sec. 38a-574. Standard underwriting form. (a) On or before July 1, 1993, the board of directors of the Connecticut Small Employer Health Reinsurance Pool shall establish, subject to the approval of the Insurance Commissioner, a standard underwriting form for use by small employer carriers for medical underwriting of health insurance plans and insurance arrangements covering small employers, as defined in section 38a-564. Within ninety days after approval by the Insurance Commissioner of the standard underwriting form the board shall require every small employer carrier, as a condition of transacting such business in this state, to use the form for medical underwriting of such plans and arrangements.

(b) The form may be amended from time to time as the board deems necessary, subject to the approval of the Insurance Commissioner.

(P.A. 93-345, S. 1, 7.)

History: P.A. 93-345 effective June 29, 1993.

Secs. 38a-575 and 38a-576. Reserved for future use.

PART VI

CONSUMER DENTAL HEALTH PLANS

Sec. 38a-577. (Formerly Sec. 38-174ii). Consumer dental health plans. Definitions. (a) For the purposes of sections 38a-577 to 38a-590, inclusive:

(1) “Capitation” means a payment system in which a dentist or group of dentists earn a fixed monthly fee from an enrolled individual or group of employees in return for providing a specific range of services for a contract year;

(2) “Commissioner” means the Insurance Commissioner;

(3) “Dental plan” means any contractual arrangement for dental services provided directly or arranged for or administered directly on a prepaid individual or group capitation basis;

(4) “Dental plan organization” means any dentist or group of dentists who undertake to provide directly or to arrange for or administer one or more dental plans providing dental services;

(5) “Dentist” means a person duly licensed under the provisions of chapter 379; and

(6) “Evidence of coverage” means any certificate, agreement or contract issued to an enrollee in a dental plan which sets forth the dental services to which the enrollee is entitled.

(b) The provisions of sections 38a-577 to 38a-590, inclusive, shall not apply to a licensed insurance company, a licensed hospital or medical service corporation or a health maintenance organization.

(P.A. 88-272, S. 1.)

History: Sec. 38-174ii transferred to Sec. 38a-577 in 1991.

Sec. 38a-578. (Formerly Sec. 38-174jj). Certificate of authority. Application requirements. (a) No dentist or group of dentists may establish, operate or administer a dental plan organization, or offer to sell, or solicit offers to purchase, or receive advance or periodic consideration in conjunction with any dental plan organization, on or after October 1, 1988, without obtaining and maintaining a certificate of authority pursuant to sections 38a-577 to 38a-590, inclusive.

(b) An application for a certificate of authority shall be in a form prescribed by the commissioner, shall be verified by an officer or authorized representative of the dental plan organization and shall include the following: (1) All basic organizational documents of the dental plan organization such as the articles of incorporation, articles of association, partnership agreement, trade name certificate, trust agreement, shareholder agreement or other applicable document and all amendments to those documents; (2) the bylaws, rules and regulations or similar documents regulating the conduct or the internal affairs of the dental plan organization; (3) the names, addresses and official positions of the persons who are responsible for the conduct of the affairs of the dental plan organization, including all members of the board of directors, board of trustees, executive committee or other governing board or committee, the principal officers in the case of a corporation and the partners or members in the case of a partnership or association; (4) all contracts made between any dentist and the dental plan organization; (5) all contracts made between any dentist and any person listed in subdivision (3) of this subsection, any consultant or any business manager; (6) a description of the dental plan organization, its dental plan or plans, facilities and personnel; (7) the form of any group contract which is issued to employers, unions, trustees or others; (8) financial statements showing the dental plan organization’s assets, liabilities and sources of financial support. If the dental plan organization’s financial affairs are audited by independent certified public accountants, a copy of the most recent regular certified financial statement shall satisfy this requirement unless the commissioner determines that additional or more recent financial information is required for the proper administration of sections 38a-577 to 38a-590, inclusive; (9) the proposed method of marketing the plan, a financial plan with a three-year projection of the initial operating results and a statement of the sources of working capital and any other sources of funding; (10) a description of the geographic area or areas to be served; (11) a description of the procedures and programs to be implemented to achieve an effective dental plan as required in section 38a-579; and (12) such other information as the commissioner may require.

(c) The dental plan organization shall pay a fee of one thousand dollars to the commissioner upon filing an application for a certificate of authority.

(d) Within ten days following any significant change in the information submitted with the application for a certificate of authority, a dental plan organization shall file notice of such change with the commissioner for his approval.

(P.A. 88-272, S. 2.)

History: Sec. 38-174jj transferred to Sec. 38a-578 in 1991.

Sec. 38a-579. (Formerly Sec. 38-174kk). Certificate of authority. Standards for issuance and renewal. (a) The commissioner shall issue a certificate of authority if he is satisfied that the following conditions are met: (1) The persons responsible for conducting the affairs of the dental plan organization are competent and professionally capable of providing, arranging for or administering the services offered by the plan; (2) the dental plan organization constitutes an appropriate mechanism to achieve an effective dental plan, as determined by the commissioner; (3) the dental plan organization has demonstrated the potential to provide dental services in a manner that will assure both availability and accessibility of adequate personnel and facilities; (4) the dental plan organization has arrangements for an ongoing quality of dental care assurance program; (5) the dental plan organization has a procedure to establish and maintain uniform systems of cost accounting and reports and audits that meet the requirements of the commissioner; (6) the dental plan organization is financially responsible and may reasonably be expected to meet its obligations to enrollees. In making this determination the commissioner shall consider (A) the financial soundness of the dental plan’s arrangements for services and the schedule of charges used, (B) any arrangement with an insurer or hospital or medical or dental service corporation for continuation of coverage in the event of discontinuance of the plan on an indemnity basis through a group vehicle to the end of the period for which premiums were paid to the discontinued dental plan organization, and (C) the sufficiency of an agreement with dentists for the provision of dental services; (7) whether a general surplus is maintained as required in section 38a-580; and (8) the condition or methods of operation of the dental plan organization are not such as would render its operations hazardous to its enrollees or the public.

(b) When the commissioner disapproves an application for a certificate of authority, he shall notify the dental plan organization in writing of the reasons for the disapproval.

(c) A certificate of authority shall expire one year following the date of issuance or previous renewal. If the dental plan organization remains in compliance with the requirements of sections 38a-577 to 38a-590, inclusive, and has made timely payment of the renewal fee of one hundred dollars, its certificate shall be renewed.

(P.A. 88-272, S. 3.)

History: Sec. 38-174kk transferred to Sec. 38a-579 in 1991.

Sec. 38a-580. (Formerly Sec. 38-174ll). General surplus required. The amount of a general surplus that a dental plan organization shall be required to maintain shall be seven hundred fifty thousand dollars or an amount equal to two per cent of premiums written, whichever is greater. For the purposes of this section, general surplus may be comprised of cash and such other instruments which, to the satisfaction of the commissioner, adequately protect the plan’s subscribers.

(P.A. 88-272, S. 4; P.A. 99-149.)

History: Sec. 38-174ll transferred to Sec. 38a-580 in 1991; P.A. 99-149 substituted $750,000 for $250,000 and substituted 2% for 33% re general surplus, and deleted “surety bonds” re composition of general surplus.

Sec. 38a-581. (Formerly Sec. 38-174mm). Evidence of coverage to be provided to enrollees. Approval by commissioner. (a) An enrollee shall be entitled to receive evidence of coverage or a certificate indicating specifically the nature and extent of coverage, and evidence of the total amount or percentage of payment, if any, which the enrollee is obligated to pay for dental services.

(b) No evidence of coverage or amendment thereto shall be issued or delivered to any person until a copy of the form of evidence of coverage or amendment thereto has been filed with the commissioner for his approval.

(c) Evidence of coverage shall contain a clear and complete statement of: (1) The dental services to which enrollees are entitled; (2) any limitations on the services, benefits or kind of benefits to be provided, including any charge, deductible or copayment feature; (3) where and in what manner information is available as to how services may be obtained; and (4) a readily understandable description of the dental plan organization’s method for resolving enrollees’ complaints.

(d) Any subsequent change in the evidence of coverage or the amount of percentage of payment which the enrollee is obligated to pay shall be evidenced in a separate document issued to the enrollee.

(P.A. 88-272, S. 5.)

History: Sec. 38-174mm transferred to Sec. 38a-581 in 1991.

Sec. 38a-582. (Formerly Sec. 38-174nn). Schedule of charges. Approval by commissioner. Appeal of disapproval. (a) No schedule of charges for enrollee coverage for dental services, or any amendment thereto, may be used by a dental plan organization until a copy of such schedule or amendment has been filed with the commissioner for his approval. The commissioner may disapprove the schedule of charges at any time if he finds that the charges are excessive, inadequate or unfairly discriminatory. If the commissioner disapproves the schedule of charges, he shall notify the dental plan organization within sixty days of the date of disapproval and specify in the notice the reason for his disapproval. A hearing shall be granted within twenty days after a request in writing by the dental plan organization. It shall be unlawful for any dental plan organization whose schedule of charges has been disapproved to effect any contract or issue any subscription certificate which uses the disapproved schedule of charges until a revised schedule of charges has been approved. Any dental plan organization aggrieved by the action of the commissioner pursuant to this section may appeal therefrom, in accordance with the provisions of section 4-183.

(b) Charges shall be established in accordance with actuarial principles, but charges applicable to an enrollee shall not be individually determined based on the status of his health.

(P.A. 88-272, S. 6.)

History: Sec. 38-174nn transferred to Sec. 38a-582 in 1991.

Sec. 38a-583. (Formerly Sec. 38-174oo). Records. Commissioner’s power to examine; maintenance; preservation. (a) The commissioner or his designee may investigate the business and examine the books, accounts, records and files of any dental plan organization. For such purposes the commissioner or his designee shall have reasonable access to the offices and places of business, books, accounts, papers, records and files of all dental plan organizations. A dental plan organization shall keep and use in its business such books, accounts and records as will enable the commissioner to determine whether the dental plan organization is complying with the provisions of sections 38a-577 to 38a-590, inclusive, and with the regulations adopted pursuant to said sections. A dental plan organization shall preserve its books, accounts and records for at least five years, provided preservation by photographic reproduction or records in photographic form shall constitute compliance with sections 38a-577 to 38a-590, inclusive.

(b) For the purpose of the examination, the commissioner may, within the limits of funds appropriated for such purpose, contract with such persons as he may deem advisable to conduct the same or assist therein.

(c) At the discretion of the commissioner, the Commissioner of Public Health and the State Dental Commission may participate in the investigations and examinations described in this section to verify the existence of an effective dental plan.

(d) The expenses incurred in making any examination pursuant to this section shall be assessed against and paid by the dental plan organization so examined. Upon written notice by the commissioner of the total amount of an assessment, a dental plan organization shall become liable for and shall pay the assessment to the commissioner.

(P.A. 88-272, S. 7; P.A. 93-381, S. 9, 39; P.A. 95-257, S. 12, 21, 58.)

History: Sec. 38-174oo transferred to Sec. 38a-583 in 1991; P.A. 93-381 replaced commissioner of health services with commissioner of public health and addiction services, effective July 1, 1993; P.A. 95-257 replaced Commissioner and Department of Public Health and Addiction Services with Commissioner and Department of Public Health, effective July 1, 1995.

Sec. 38a-584. (Formerly Sec. 38-174pp). Complaint system. (a) A dental plan organization shall establish and maintain a complaint system to provide reasonable procedures for the resolution of written complaints initiated by enrollees concerning dental plan services. The dental plan organization shall maintain records of all written complaints initiated by enrollees.

(b) The commissioner may examine the complaint system of any dental plan organization, and if he determines that the system is not adequate he may require a revision of the complaint system.

(P.A. 88-272, S. 8; P.A. 90-230, S. 99(c), 101.)

History: P.A. 90-230 provided that “section 38-74pp of the general statutes, appearing on page 155 of volume 11 of the general statutes, revised to 1989, shall be known as section 38-174pp unless and until renumbered by the legislative commissioner”; Sec. 38-174pp transferred to Sec. 38a-584 in 1991.

Sec. 38a-585. (Formerly Sec. 38-174qq). Requirements re filing of annual reports with commissioner. Every dental plan organization shall, on or before March first in each calendar year, file with the commissioner a report covering its activities for the preceding calendar year. The reports shall be on a form prescribed by the commissioner and shall include: (1) A financial statement of the dental plan organization, including its balance sheet, receipts and disbursements for the preceding year certified by a certified public accountant; (2) any significant modification of information submitted with the application for a certificate of authority; (3) the number of persons who became enrollees during the year, the number of enrollees as of the end of the year and the number of enrollments terminated during the year; (4) a description of the enrollee complaint system including the procedures of the complaint system, the total number of written complaints handled through the system, a summary of causes underlying the complaints filed, and the number, amount and disposition of malpractice claims settled during the year by the dental plan organization and any of the dentists used by it; and (5) any other information relating to the performance of the dental plan organization as required by the commissioner.

(P.A. 88-272, S. 9.)

History: Sec. 38-174qq transferred to Sec. 38a-585 in 1991.

Sec. 38a-586. (Formerly Sec. 38-174rr). False or misleading advertising or solicitation and deceptive evidence of coverage prohibited. (a) No dental plan organization or representative thereof may cause or knowingly permit the use of advertising which is untrue or misleading, solicitation which is untrue or misleading, or any form of evidence of coverage which is deceptive. For purposes of sections 38a-577 to 38a-590, inclusive: (1) A statement or item of information shall be deemed to be untrue if it does not conform to fact in any respect which is or may be significant to an enrollee of, or person considering enrollment in, a dental plan; (2) a statement or item of information shall be deemed to be misleading whether or not it may be literally true, if, in the total context in which the statement is made or the item of information is communicated, the statement or item of information may be reasonably understood by a person who does not possess special knowledge regarding dental plan coverage as indicating any benefit or advantage or the absence of any exclusion, limitation, or disadvantage of possible significance to an enrollee of, or person considering enrollment in, a dental plan if the benefit or advantage or absence of exclusion, limitation, or disadvantage does not in fact exist; and (3) evidence of coverage shall be deemed to be deceptive if the evidence of coverage taken as a whole, and with consideration given to typography, format and language, may cause a person who does not possess special knowledge regarding dental plans and evidence of coverage therefor, to expect benefits, services, charges or other advantages which the evidence of coverage does not provide or which the dental plan organization issuing the evidence of coverage does not regularly make available for enrollees covered under such evidence of coverage.

(b) No dental plan organization, unless licensed as an insurer, may use in its name, evidence of coverage or literature any of the words “insurance”, “assurance”, “casualty”, “surety”, “mutual” or any other words descriptive of the insurance, casualty or surety business or deceptively similar to the name or description of any insurer licensed to do business in this state.

(P.A. 88-272, S. 10.)

History: Sec. 38-174rr transferred to Sec. 38a-586 in 1991.

Sec. 38a-587. (Formerly Sec. 38-174ss). Suspension or revocation of certificate of authority. Hearing. Appeal. (a) The commissioner may suspend or revoke any certificate of authority issued to a dental plan organization pursuant to sections 38a-577 to 38a-590, inclusive, if he finds that any of the following conditions exist: (1) The dental plan organization is operating in a manner significantly contrary to that described in section 38a-578; (2) the dental plan organization issues an evidence of coverage which does not comply with the requirements of section 38a-582; (3) the dental plan organization does not provide or arrange for an effective dental plan as determined by the commissioner; (4) the dental plan organization can no longer be expected to meet its obligations to enrollees; (5) the dental plan organization, or any authorized person on its behalf, has advertised or merchandised its services in an untrue or misleading manner as described in section 38a-586; or (6) the dental plan organization has failed to comply with sections 38a-577 to 38a-590, inclusive, or any regulations adopted pursuant thereto.

(b) When the commissioner has cause to believe that grounds for the suspension or revocation of a certificate of authority exist, he shall notify the dental plan organization in writing, specifically stating the grounds for suspension or revocation. A hearing on the matter shall be granted by the commissioner within twenty days after such notification. After the hearing, or upon failure of the dental plan organization to appear at the hearing, the commissioner shall take action on his findings.

(c) If the commissioner suspends the certificate of authority, the dental plan organization shall not accept any additional enrollees or engage in any advertising or solicitation during the period of the suspension.

(d) If the commissioner revokes the certificate of authority, the dental plan organization shall proceed to dissolve its structure immediately following the effective date of the order of revocation, and shall conduct no further business except as may be essential to the orderly conclusion of the affairs of the dental plan organization. The commissioner by written order may permit such further operation of the dental plan organization as he finds to be in the best interest of enrollees to the end that enrollees shall be afforded the greatest practical opportunity to obtain continuing dental plan coverage.

(e) The commissioner may issue an order directing a dental plan organization or a representative of a dental plan organization to cease and desist from engaging in any act or practice in violation of the provisions of sections 38a-577 to 38a-590, inclusive. Within twenty days after service of the order of cease and desist, the respondent may request a hearing on the question of whether acts or practices in violation of said sections have occurred. The hearing shall be provided within twenty days of such request.

(f) Any dental plan organization which has had its certificate of authority suspended or revoked, or has otherwise been aggrieved by the action of the commissioner pursuant to this section, may appeal therefrom in accordance with the provisions of section 4-183.

(P.A. 88-272, S. 11.)

History: Sec. 38-174ss transferred to Sec. 38a-587 in 1991.

Sec. 38a-588. (Formerly Sec. 38-174tt). Penalty. Insolvency. Any dental plan organization that violates any provision of sections 38a-577 to 38a-590, inclusive, or neglects, fails or refuses to comply with any of the requirements of said sections, except the failure to file an annual report and the failure to reply in writing to inquiries of the commissioner, shall be liable for a civil penalty of not more than one thousand five hundred dollars for each violation. The commissioner may bring a civil action to recover the amount of a civil penalty.

(P.A. 88-272, S. 12; P.A. 96-227, S. 10; P.A. 08-178, S. 19.)

History: Sec. 38-174tt transferred to Sec. 38a-588 in 1991; P.A. 96-227 deleted Subsec. (b) which required the commissioner to invoke the Insurers Rehabilitation and Liquidation Act re insolvent dental plans; P.A. 08-178 made a technical change and increased maximum penalty from $1,000 to $1,500 per violation.

Sec. 38a-589. (Formerly Sec. 38-174uu). Confidentiality. (a) Applications, filings and reports required under sections 38a-577 to 38a-590, inclusive, except contracts referred to in subdivisions (4) and (5) of subsection (b) of section 38a-578, shall be public records.

(b) Data or information pertaining to the diagnosis, treatment or health of any enrollee obtained by the dental plan organization from the enrollee or any dentist shall be confidential and shall not be disclosed to any person except to the extent that it may be necessary to carry out the purposes of sections 38a-577 to 38a-590, inclusive, or upon the express consent of the enrollee, or pursuant to statute or court order for the production of evidence or the discovery thereof, or in the event of claim or litigation between the enrollee and the dental plan organization wherein the data or information is pertinent. A dental plan organization shall be entitled to claim any statutory privileges against such disclosure which the dentist who furnished the information to the dental organization is entitled to claim.

(P.A. 88-272, S. 13.)

History: Sec. 38-174uu transferred to Sec. 38a-589 in 1991.

Sec. 38a-590. (Formerly Sec. 38-174vv). Commissioner’s power to adopt regulations. The commissioner may adopt regulations, in accordance with the provisions of chapter 54, as he deems necessary to effect the purposes of sections 38a-577 to 38a-590, inclusive.

(P.A. 88-272, S. 14.)

History: Sec. 38-174vv transferred to Sec. 38a-590 in 1991.

PART VII

GRIEVANCES AND EXTERNAL REVIEWS

Sec. 38a-591. Compliance with the Patient Protection and Affordable Care Act. Regulations. (a) For purposes of this section, “Affordable Care Act” means the Patient Protection and Affordable Care Act, P.L. 111-148, as amended from time to time, and regulations adopted thereunder.

(b) Each insurance company, fraternal benefit society, hospital service corporation, medical service corporation and health care center licensed to do business in the state shall comply with Sections 1251, 1252 and 1304 of the Affordable Care Act and the following Sections of the Public Health Service Act, as amended by the Affordable Care Act: (1) 2701 to 2709, inclusive, 42 USC 300gg et seq.; (2) 2711 to 2719A, inclusive, 42 USC 300gg-11 et seq.; and (3) 2794, 42 USC 300gg-94.

(c) This section shall apply, on and after the effective dates specified in the Affordable Care Act, to insurance companies, fraternal benefit societies, hospital service corporations, medical service corporations and health care centers licensed to do business in the state.

(d) No provision of the general statutes concerning a requirement of the Affordable Care Act shall be construed to supersede a provision of the general statutes that provides greater protection to an insured, except to the extent the latter prevents the application of a requirement of the Affordable Care Act.

(e) The Insurance Commissioner may adopt regulations, in accordance with the provisions of chapter 54, to implement the provisions of this section.

(P.A. 11-58, S. 53.)

History: P.A. 11-58 effective July 2, 2011.

Sec. 38a-591a. Definitions. As used in this section and sections 38a-591b to 38a-591n, inclusive:

(1) “Adverse determination” means:

(A) The denial, reduction, termination or failure to provide or make payment, in whole or in part, for a benefit under the health carrier’s health benefit plan requested by a covered person or a covered person’s treating health care professional, based on a determination by a health carrier or its designee utilization review company:

(i) That, based upon the information provided, (I) upon application of any utilization review technique, such benefit does not meet the health carrier’s requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness, or (II) is determined to be experimental or investigational;

(ii) Of a covered person’s eligibility to participate in the health carrier’s health benefit plan; or

(B) Any prospective review, concurrent review or retrospective review determination that denies, reduces or terminates or fails to provide or make payment, in whole or in part, for a benefit under the health carrier’s health benefit plan requested by a covered person or a covered person’s treating health care professional.

“Adverse determination” includes a rescission of coverage determination for grievance purposes.

(2) “Authorized representative” means:

(A) A person to whom a covered person has given express written consent to represent the covered person for the purposes of this section and sections 38a-591b to 38a-591n, inclusive;

(B) A person authorized by law to provide substituted consent for a covered person;

(C) A family member of the covered person or the covered person’s treating health care professional when the covered person is unable to provide consent;

(D) A health care professional when the covered person’s health benefit plan requires that a request for a benefit under the plan be initiated by the health care professional; or

(E) In the case of an urgent care request, a health care professional with knowledge of the covered person’s medical condition.

(3) “Best evidence” means evidence based on (A) randomized clinical trials, (B) if randomized clinical trials are not available, cohort studies or case-control studies, (C) if such trials and studies are not available, case-series, or (D) if such trials, studies and case-series are not available, expert opinion.

(4) “Case-control study” means a retrospective evaluation of two groups of patients with different outcomes to determine which specific interventions the patients received.

(5) “Case-series” means an evaluation of a series of patients with a particular outcome, without the use of a control group.

(6) “Certification” means a determination by a health carrier or its designee utilization review company that a request for a benefit under the health carrier’s health benefit plan has been reviewed and, based on the information provided, satisfies the health carrier’s requirements for medical necessity, appropriateness, health care setting, level of care and effectiveness.

(7) “Clinical peer” means a physician or other health care professional who holds a nonrestricted license in a state of the United States and in the same or similar specialty as typically manages the medical condition, procedure or treatment under review.

(8) “Clinical review criteria” means the written screening procedures, decision abstracts, clinical protocols and practice guidelines used by the health carrier to determine the medical necessity and appropriateness of health care services.

(9) “Cohort study” means a prospective evaluation of two groups of patients with only one group of patients receiving a specific intervention or specific interventions.

(10) “Commissioner” means the Insurance Commissioner.

(11) “Concurrent review” means utilization review conducted during a patient’s stay or course of treatment in a facility, the office of a health care professional or other inpatient or outpatient health care setting, including home care.

(12) “Covered benefits” or “benefits” means health care services to which a covered person is entitled under the terms of a health benefit plan.

(13) “Covered person” means a policyholder, subscriber, enrollee or other individual participating in a health benefit plan.

(14) “Emergency medical condition” means a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that a prudent layperson with an average knowledge of health and medicine, acting reasonably, would have believed that the absence of immediate medical attention would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person’s health or, with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy.

(15) “Emergency services” means, with respect to an emergency medical condition:

(A) A medical screening examination that is within the capability of the emergency department of a hospital, including ancillary services routinely available to the emergency department to evaluate such emergency medical condition; and

(B) Such further medical examination and treatment, to the extent they are within the capability of the staff and facilities available at a hospital, to stabilize a patient.

(16) “Evidence-based standard” means the conscientious, explicit and judicious use of the current best evidence based on an overall systematic review of medical research when making determinations about the care of individual patients.

(17) “Expert opinion” means a belief or an interpretation by specialists with experience in a specific area about the scientific evidence pertaining to a particular service, intervention or therapy.

(18) “Facility” means an institution providing health care services or a health care setting. “Facility” includes a hospital and other licensed inpatient center, ambulatory surgical or treatment center, skilled nursing center, residential treatment center, diagnostic, laboratory and imaging center, and rehabilitation and other therapeutic health care setting.

(19) “Final adverse determination” means an adverse determination (A) that has been upheld by the health carrier at the completion of its internal grievance process, or (B) for which the internal grievance process has been deemed exhausted.

(20) “Grievance” means a written complaint or, if the complaint involves an urgent care request, an oral complaint, submitted by or on behalf of a covered person regarding:

(A) The availability, delivery or quality of health care services, including a complaint regarding an adverse determination made pursuant to utilization review;

(B) Claims payment, handling or reimbursement for health care services; or

(C) Any matter pertaining to the contractual relationship between a covered person and a health carrier.

(21) (A) “Health benefit plan” means an insurance policy or contract, certificate or agreement offered, delivered, issued for delivery, renewed, amended or continued in this state to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services;

(B) “Health benefit plan” does not include:

(i) Coverage of the type specified in subdivisions (5) to (9), inclusive, (14) and (15) of section 38a-469 or any combination thereof;

(ii) Coverage issued as a supplement to liability insurance;

(iii) Liability insurance, including general liability insurance and automobile liability insurance;

(iv) Workers’ compensation insurance;

(v) Automobile medical payment insurance;

(vi) Credit insurance;

(vii) Coverage for on-site medical clinics;

(viii) Other insurance coverage similar to the coverages specified in subparagraphs (B)(ii) to (B)(vii), inclusive, of this subdivision that are specified in regulations issued pursuant to the Health Insurance Portability and Accountability Act of 1996, P.L. 104-191, as amended from time to time, under which benefits for health care services are secondary or incidental to other insurance benefits;

(ix) (I) Limited scope dental or vision benefits, (II) benefits for long-term care, nursing home care, home health care, community-based care or any combination thereof, or (III) other similar, limited benefits specified in regulations issued pursuant to the Health Insurance Portability and Accountability Act of 1996, P.L. 104-191, as amended from time to time, provided any benefits specified in subparagraphs (B)(ix)(I) to (B)(ix)(III), inclusive, of this subdivision are provided under a separate insurance policy, certificate or contract and are not otherwise an integral part of a health benefit plan; or

(x) Coverage of the type specified in subdivisions (3) and (13) of section 38a-469 or other fixed indemnity insurance if (I) they are provided under a separate insurance policy, certificate or contract, (II) there is no coordination between the provision of the benefits and any exclusion of benefits under any group health plan maintained by the same plan sponsor, and (III) the benefits are paid with respect to an event without regard to whether benefits were also provided under any group health plan maintained by the same plan sponsor.

(22) “Health care center” has the same meaning as provided in section 38a-175.

(23) “Health care professional” means a physician or other health care practitioner licensed, accredited or certified to perform specified health care services consistent with state law.

(24) “Health care services” has the same meaning as provided in section 38a-478.

(25) “Health carrier” means an entity subject to the insurance laws and regulations of this state or subject to the jurisdiction of the commissioner, that contracts or offers to contract to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services, including a sickness and accident insurance company, a health care center, a managed care organization, a hospital service corporation, a medical service corporation or any other entity providing