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-473. Medicare supplement expense factors. Age, gender, previous claim or medical
history rating prohibited. Exceptions.
Sec. 38a-474. Rate increases: Procedure. Age, gender, previous claim or medical history
rating prohibited. Exceptions.
Sec. 38a-475. Precertification of 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-477. Standardized claim forms. Regulations.
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.
Commission'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 removal from list
of enrollee's primary care physician.
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.
Sec. 38a-478m. Internal grievance procedure. Duty to establish and notify enrollees of
procedure. Deadline for resolving complaints.
Sec. 38a-478n. Internal grievances. Appeal to the commissioner. Fees. Public education
outreach program.
Sec. 38a-478o. Confidentiality and antidiscrimination procedures required.
Sec. 38a-478p. Expedited utilization review. Standardized form 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. ERISA. Workers' compensation. Nonapplicability.
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.
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 and policy form by commissioner. Exception re Medicare supplement policy. Filing, form and minimum provisions of loss ratio guarantee. Regulations. Age, gender, previous claim or medical history rating prohibited. Exceptions. Optional life insurance riders.
Sec. 38a-482. (Formerly Sec. 38-166). Form of policy.
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-489. (Formerly Sec. 38-174e). Continuation of coverage of mentally or physically
handicapped children.
Sec. 38a-490. (Formerly Sec. 38-174g). Coverage for newborn infants in health insurance
policies. Notice. Application.
Sec. 38a-490a. Coverage for birth-to-three program.
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 amino acid modified preparations and low protein modified
food products.
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.
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-493. (Formerly Sec. 38-174k). Mandatory coverage required in health insurance
for home health care.
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. Premium rates charged on a community rate basis. Age, gender, previous
claim or medical history rating prohibited. Exceptions. Medicare supplement policies for
the disabled.
Sec. 38a-496. (Formerly Sec. 38-174q). Coverage for occupational therapy. Definitions.
Benefits.
Sec. 38a-497. (Formerly Sec. 38-174r). Termination of coverage of children in individual
policies.
Sec. 38a-497a. Group coverage and benefits of a noncustodial parent. Notification of new
employer by IV-D agency. Notification to custodial 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-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 and Hospital.
Sec. 38a-503. (Formerly Sec. 38-174gg). Mandatory coverage for mammography.
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 and chemotherapy. Mandatory coverage for breast reconstruction after mastectomy.
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.
Secs. 38a-509 to 38a-511.
Sec. 38a-512. Applicability.
Sec. 38a-513. Approval of group health insurance policy forms. Age, gender, previous
claim or medical history rating prohibited. Exceptions. Optional life insurance riders.
Sec. 38a-513a. Time limits for coverage determinations. Notice requirements.
Sec. 38a-513b. Coverage and notice re experimental treatments. Appeals.
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-515. Continuation of coverage of mentally retarded or physically handicapped dependent children.
Sec. 38a-516. Coverage for newborn infants in health insurance policies. Notice. Application.
Sec. 38a-516a. Coverage for birth-to-three program.
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 amino acid modified preparations and low protein modified
food products.
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.
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-519. (Formerly Sec. 38-174j). Offset proviso prohibited in certain policies.
Sec. 38a-520. Mandatory coverage required in health insurance for home health care.
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. Definitions. Benefits.
Sec. 38a-525. Mandatory coverage for emergency ambulance services. Direct payment to ambulance provider.
Sec. 38a-525a. Preauthorization prohibited for certain 9-1-1 emergency calls.
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 service provided by the Veterans' Home and Hospital.
Sec. 38a-530. Mandatory coverage for mammography.
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). Required coverage for certain employees. 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. Mandatory coverage for chiropractic services.
Sec. 38a-535. Mandatory coverage for preventive pediatric care.
Sec. 38a-535a. Notification of individual coverage and benefits of a noncustodial parent
to a custodial parent, when. Regulations.
Sec. 38a-536. Group hospital or medical expense insurance policy coverage for infertility.
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, prothesis and chemotherapy. Mandatory coverage for breast reconstruction after mastectomy.
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). Continuation of benefits under group health policies.
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.
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. Managed care plans.
Sec. 38a-554. (Formerly Sec. 38-374). Additional requirements and eligibility under group
comprehensive health care plans. 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-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.
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.
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.
Secs. 38a-591 to 38a-594.
HEALTH INSURANCE: IN GENERAL
Sec. 38a-469. Definitions. As used in title 38a, 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. 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. 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. 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. 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. 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. Sec. 38a-473. Medicare supplement expense factors. Age, gender, previous
claim or medical history rating prohibited. Exceptions. (a) No insurance company,
fraternal benefit society, hospital service corporation, medical service corporation,
health care center or any 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 thereunder, 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. Sec. 38a-474. Rate increases: Procedure. Age, gender, previous claim or medical history rating prohibited. Exceptions. (a) On or after October 1, 1990, any insurance company, fraternal benefit society, hospital service corporation or medical service
corporation, and on and after January 1, 1994, any health care center or any other entity
which delivers, 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, 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 within forty-five days of its receipt. The Insurance Commissioner
shall adopt regulations, in accordance with the provisions of 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. Sec. 38a-475. Precertification of 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 17a-307; (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. 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. 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. Sec. 38a-477. Standardized claim forms. 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 UB-82 or its successor, or in accordance with other
forms which may be prescribed by the Insurance Commissioner. Sec. 38a-478. Definitions. As used in sections 38a-478 to 38a-478o, inclusive, and
subsection (a) of section 38a-478s: Sec. 38a-478a. Commissioner's report to the Governor and the General Assembly. On March 1, 1999, and annually thereafter, 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 relating to insurance, concerning the commissioner's responsibilities under the provisions of sections
19a-647, 38a-226 to 38a-226d, inclusive, 38a-478 to 38a-478u, 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, 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, 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 received by the Insurance
Department's Consumer Affairs Division and the commissioner under section 38a-
478n, 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; 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. Sec. 38a-478b. Penalty for managed care organization's failure to file data
and reports. Commission'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 19a-647, 38a-226 to 38a-226d, inclusive, 38a-478 to 38a-478u, 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. Sec. 38a-478c. Managed care organization's report to the commissioner:
Data, reports and information required. (a) On or before May 1, 1998, and annually
thereafter, each managed care organization shall submit to the commissioner: Sec. 38a-478d. List of providers required. Notification to enrollee of removal
from list of enrollee's primary care physician. For any contract delivered, issued for
delivery, renewed, amended or continued in this state on or after October 1, 1997, each
managed care organization shall provide: (1) Annually to each enrollee a listing of all
providers available under the provisions of the enrollee's enrollment agreement; and
(2) notification, as soon as possible, to each enrollee upon the termination or withdrawal
of the enrollee's primary care physician. 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. 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. 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 on or after October 1, 1997, 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. 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 on and after October 1, 1997, 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. Sec. 38a-478i. Limitation on enrollee rights prohibited. No contract delivered,
issued for delivery, renewed, amended or continued in this state on and after October
1, 1997, between a managed care organization and a participating provider shall prohibit
or limit any cause of action or contract rights an enrollee otherwise has. 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. Sec. 38a-478k. Gag clauses prohibited. (a) No contract delivered, issued for delivery, renewed, amended or continued in this state on and after October 1, 1997, 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. Sec. 38a-478l. Consumer report card required. Content. (a) Not later than
March 15, 1999, and annually thereafter, 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. Sec. 38a-478m. Internal grievance procedure. Duty to establish and notify enrollees of procedure. Deadline for resolving complaints. (a) Each managed care organization shall establish and maintain an internal grievance procedure to assure that enrollees may seek a review of any grievance that may arise from a managed care
organization's action or inaction, other than action or inaction based on utilization review, and obtain a timely resolution of any such grievance. Such grievance procedure
shall comply with the following requirements: Sec. 38a-478n. Internal grievances. Appeal to the commissioner. Fees. Public
education outreach program. (a) On or after January 1, 1998, any enrollee, or any
provider acting on behalf of an enrollee with the enrollee's consent, who has exhausted
the internal mechanisms provided by a managed care organization or utilization review
company to appeal a determination not to certify an admission, service, procedure or
extension of stay, may appeal such determination to the commissioner. 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. Sec. 38a-478p. Expedited utilization review. Standardized form required. (a)
On or before October 1, 1997, the Insurance Commissioner shall develop a standardized
process for use in seeking expedited utilization review approval pursuant to section 38a-
226c. In developing such standardized process, the commissioner may convene and
consult with a working group composed of a representative of: The Connecticut Medical
Society, the Connecticut Hospital Association, Blue Cross Blue Shield of Connecticut,
and the Association of Connecticut HMOs. 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. 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. Sec. 38a-478s. ERISA. Workers' compensation. Nonapplicability. (a) Nothing
in sections 38a-478 to 38a-478o, inclusive, shall be construed to apply to the arrangements of managed care organizations offered to individuals covered under self-insured
employee welfare benefit plans established pursuant to the federal Employee Retirement
Income Security Act of 1974. 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 19a-647,
38a-226 to 38a-226d, inclusive, 38a-478 to 38a-478u, inclusive, and 38a-993. Sec. 38a-478u. Regulations. The Insurance Commissioner shall adopt regulations
in accordance with the provisions of chapter 54 to implement the provisions of sections
19a-647, 38a-226 to 38a-226d, inclusive, 38a-478 to 38a-478u, inclusive, and 38a-993. 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. Sec. 38a-479. Reserved for future use. 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.
(P.A. 90-243, S. 68; P.A. 96-227, S. 9.)
History: P.A. 96-227 added "specified disease coverage" as a type of "health insurance" policy.
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(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). 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.)
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.
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. 439−441, 444, 448, 449, 452, 458.
Cited. 22 CA 539, 544, 546−548; judgment reversed, see 219 C. 439 et seq.
Subsec. (b):
Cited. 217 C. 631, 640.
Cited. 22 CA 27, 35; judgment reversed, see 217 C. 631 et seq.
Subsec. (c):
Cited. 22 CA 539, 544, 546; judgment reversed, see 219 C. 439 et seq.
Annotations to present section:
Cited. 219 C. 439−441, 444, 448, 449, 452, 458.
Subsec. (b):
Cited. 217 C. 631, 640.
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(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.
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(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 general assistance
program, the state-administered general assistance program or 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.)
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.
Annotations to former section 38-174a:
Subsec. (b):
Cited. 219 C. 439, 442.
Annotations to present section:
Cited. 219 C. 439, 442.
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(P.A. 95-199, S. 3.)
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(P.A. 95-199, S. 4.)
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(b) No insurance company, fraternal benefit society, hospital service corporation,
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, shall
incorporate in its rates 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, except for plans "H" to "J",
inclusive, as provided in section 38a-495b. In plans "H" to "J", inclusive, previous
claims history and the medical condition of the applicant may be used in determining
rates and granting coverage under Medicare supplement policies and certificates.
(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.)
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.
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(b) No insurance company, fraternal benefit society, hospital service corporation,
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, shall
incorporate in its rates 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, except for plans "H" to "J",
inclusive, as provided in section 38a-495b. In plans "H" to "J", inclusive, previous
claims history and the medical condition of the applicant may be used in determining
rates and granting coverage under Medicare supplement policies and certificates.
(P.A. 90-81; P.A. 91-406, S. 10, 29; P.A. 93-390, S. 4, 8; P.A. 94-39, S. 4.)
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.
See Sec. 38a-481 re Medicare supplement policy rates.
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(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.)
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.
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.
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(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 may impose a
preexisting conditions provision which excludes coverage for a period beyond twelve
months following the insured's effective date of coverage. Any preexisting conditions
provision may 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 may impose a
preexisting conditions provision which excludes coverage beyond twelve months following the insured's effective date of coverage. Any preexisting conditions provision
may only relate to conditions, whether physical or mental, which manifest themselves, or
for which medical advice, diagnosis or care or treatment was recommended or received
during the twelve months immediately preceding the effective date of coverage.
(c) All health insurance plans and insurance arrangements shall provide coverage,
under the terms and conditions of its 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) A short-term health insurance policy issued on a nonrenewable basis for six
months or less shall not be subject to this section, provided, any policy, application
or sales brochure issued for such short-term insurance which imposes a preexisting
conditions provision shall disclose that such preexisting conditions are not covered.
(h) The commissioner may adopt regulations, in accordance with the provisions of
chapter 54, to enforce the provisions of HIPAA 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.)
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 sixty-three to one hundred
twenty days and ninety to one hundred fifty days, amending application deadline from sixty-three to thirty days, and making
technical changes for purposes of gender neutrality.
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(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.
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(b) The commissioner may adopt regulations in accordance with the provisions of
chapter 54 to implement the provisions of subsection (a) of this section.
(P.A. 93-109.)
*See Sec. 19a-647 re preferred provider networks.
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HEALTH INSURANCE: MANAGED CARE
(1) "Commissioner" means the Insurance Commissioner.
(2) "Managed care organization" means an insurer, health care center, hospital or
medical service corporation or other organization delivering, issuing for delivery, renewing or amending any individual or group health managed care plan in this state.
(3) "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 that the
plan includes utilization review pursuant to sections 38a-226 to 38a-226d, inclusive.
(4) "Provider" means a person licensed to provide health care services under chapters 370 to 373, inclusive, 375 to 383b, inclusive, 384a to 384c, inclusive, or chapter 400j.
(5) "Enrollee" means a person who has contracted for or who participates in a managed care plan for himself or his eligible dependents.
(P.A. 97-99, S. 1.)
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(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.)
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.
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(b) On June 1, 1998, and annually thereafter, 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 matters relating to insurance, a list of
those managed care organizations that have failed to file any data, report or information
required by sections 19a-647, 38a-226 to 38a-226d, inclusive, 38a-478 to 38a-478u,
inclusive, and 38a-993.
(P.A. 97-99, S. 3; P.A. 99-284, S. 52, 60; P.A. 00-196, S. 23.)
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).
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(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 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;
(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 1, 1998, and annually thereafter, 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 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 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 he is required to develop and distribute 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 medical loss ratio or percentage
of the total premium revenues spent on medical care compared to administrative costs
and plan marketing, how it compensates health care providers and its premium level;
(C) a description of services, the number of primary care physicians and specialists, and
distribution and the 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 speciality care provider, the percentage of primary and speciality 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.
(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.
(P.A. 97-99, S. 4; P.A. 98-27, S. 19.)
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.
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(P.A. 97-99, S. 5.)
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(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.
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(P.A. 97-99, S. 7.)
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(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 to 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 medical loss ratio, or percentage of total premium revenue spent on medical
care compared to administrative costs and plan marketing;
(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.)
History: June 18 Sp. Sess. P.A. 97-8 amended Subsec. (a) by deleting requirement of conformance to federal Health
Maintenance Organization Act in Subdiv. (4) and deleting reference to filing in Subdiv. (16) and amended Subsec. (b) by
adding provision re procedure for obtaining information on the availability of specific drugs in Subdiv. (5), effective July
1, 1997.
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(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 subsection (e) of section 38a-226c or section 38a-478n.
(P.A. 97-99, S. 9.)
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(P.A. 97-99, S. 10.)
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(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.
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(b) No contract delivered, issued for delivery, renewed, amended or continued in
this state on and after October 1, 1997, 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.)
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(b) The consumer report card shall include (1) all health care centers licensed pursuant to chapter 698a and (2) the fifteen largest licensed health insurers that use provider
networks and that are not included in subdivision (1) of this subsection. The insurers
selected pursuant to subdivision (2) of this subsection shall be selected on the basis of
Connecticut direct written health premiums from such network plans.
(c) 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.
(P.A. 97-99, S. 13.)
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(1) Enrollees shall be informed of the grievance procedure at the time of initial
enrollment and at not less than annual intervals thereafter, which notification may be
met by inclusion in an enrollment agreement or update. Enrollees shall also be informed
of the grievance procedure when a decision has been made not to certify an admission,
service or extension of stay.
(2) Notices to enrollees describing the grievance procedure shall explain: (A) The
process for filing a grievance with the managed care organization, which may be communicated orally, electronically or in writing; (B) that the enrollee, a person acting on behalf
of an enrollee, including the enrollee's health care provider, may make a request for
review of a grievance; and (C) the time periods within which the managed care organization must resolve the grievance.
(b) All reviews conducted under this section shall be resolved not later than sixty
days from the date the enrollee commences the complaint, unless an extension is requested by the enrollee.
(P.A. 97-99, S. 14; P.A 99-284, S. 35.)
History: P.A. 99-284 designated existing provisions as Subsec. (a), amending Subdiv. (1) by requiring enrollees to be
informed of the grievance procedure and amending Subdiv. (2) by allowing other forms of communication, and added
new Subsec. (b) re reviews within sixty days.
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(b) (1) To appeal a decision under the provisions of this section, an enrollee or any
provider acting on behalf of an enrollee shall, within thirty days from receiving a final
written determination from the enrollee's managed care organization or utilization review company, file a written request with the commissioner. The appeal shall be on
forms prescribed by said commissioner and shall include the filing fee provided for in
subdivision (2) of this section and a general release executed by the enrollee for all
medical records pertinent to the appeal.
(2) The filing fee shall be twenty-five dollars and shall be deposited into the Insurance Fund established in section 38a-52. If the commissioner finds that an enrollee is
indigent or unable to pay the fee, the commissioner shall waive the fee.
(3) Upon receipt of the appeal together with the executed release and appropriate
fee, the commissioner shall assign the appeal for review to an entity as defined in subsection (c) of this section.
(4) Upon receipt of the request for appeal from the commissioner, the entity conducting the appeal shall conduct a preliminary review of the appeal and accept it if
such entity determines: (A) The individual was or is an enrollee of the managed care
organization; (B) the benefit or service that is the subject of the complaint or appeal
reasonably appears to be a covered service, benefit or service under the agreement provided by contract to the enrollee; (C) the enrollee has exhausted all internal appeal
mechanisms provided; (D) the enrollee has provided all information required by the
commissioner to make a preliminary determination including the appeal form, a copy of
the final decision of denial and a fully-executed release to obtain any necessary medical
records from the managed care organization and any other relevant provider.
(5) Upon completion of the preliminary review, the entity conducting such review
shall immediately notify the member or provider, as applicable, in writing as to whether
the appeal has been accepted for full review and, if not so accepted, the reasons therefor.
(6) If accepted for full review, the entity shall conduct such review in accordance
with the regulations adopted by the commissioner, after consultation with the Commissioner of Public Health, in accordance with the provisions of chapter 54.
(c) To provide for such appeal the Insurance Commissioner, after consultation with
the Commissioner of Public Health, shall engage impartial health entities to provide for
medical review under the provisions of this section. Such review entities shall include
(1) medical peer review organizations, (2) independent utilization review companies,
provided any such organizations or companies are not related to or associated with any
managed care organization and (3) nationally recognized health experts or institutions
approved by the commissioner.
(d) The commissioner shall accept the decision of the reviewing entity and the decision of the commissioner shall be binding.
(e) Not later than January 1, 2000, the Insurance Commissioner shall develop a
comprehensive public education outreach program to educate health insurance consumers of the existence of the appeals procedure established in this section. The program
shall maximize public information concerning the appeals procedure and shall include,
but not be limited to: (1) The dissemination of information through mass media, interactive approaches and written materials; (2) involvement of community-based organizations in developing messages and in devising and implementing education strategies;
and (3) periodic evaluations of the effectiveness of educational efforts. The Managed
Care Ombudsman shall coordinate the outreach program and oversee the education
process.
(P.A. 97-99, S. 20; June 18 Sp. Sess. P.A. 97-8, S. 60, 88; P.A. 99--284, S. 14, 60.)
History: June 18 Sp. Sess. P.A. 97-8 amended Subdiv. (2) of Subsec. (b) to require that the fee be deposited in the
Insurance Fund, effective July 1, 1997; P.A. 99-284, which was added editorially by the Revisors as Subsec. (e), required
the commissioner to develop a public education outreach program and required the ombudsman to coordinate the program
and oversee the education process, effective July 7, 1999.
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(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".
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(b) The process developed pursuant to subsection (a) of this section shall be distributed to all acute care hospitals in this state and shall be revised as deemed necessary by
the commissioner.
(P.A. 97-99, S. 22, 32.)
History: P.A. 97-99 effective June 6, 1997.
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(P.A. 97-99, S. 25.)
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(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, after consultation with the working group convened pursuant to section 38a-478p, 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.)
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.
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(b) The provisions of sections 38a-478 to 38a-478o, inclusive, 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.)
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.
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(P.A. 97-99, S. 31; P.A. 99-284, S. 54, 60.)
History: P.A. 99-284 deleted obsolete reference to Sec. 38a-514a, effective January 1, 2000.
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(P.A. 97-99, S. 29; P.A. 99-284, S. 55, 60.)
History: P.A. 99-284 deleted obsolete reference to Sec. 38a-514a, effective January 1, 2000.
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(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.)
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INDIVIDUAL HEALTH INSURANCE
(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.
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