CHAPTER 700c
HEALTH INSURANCE

Table of Contents

Sec. 38a-469. Definitions.
Sec. 38a-470. (Formerly Sec. 38-174n). Lien on workers' compensation awards for insurers. Notice of lien.
Sec. 38a-471. (Formerly Sec. 38-174o). Third party prescription programs. Notice of cancellation. Applicability of section.
Sec. 38a-472. (Formerly Sec. 38-174a). Assignment of insurance proceeds to doctor, hospital or state agency. Lien for state care. Notice of lien.
Sec. 38a-472a. Medical provider indemnification agreements prohibited.
Sec. 38a-472b. Medical provider indemnification contracts. Professional actions and related liability.
Sec. 38a-472c. Dental policies. Estimate of reimbursement.
Sec. 38a-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 long-term care policies under the Connecticut Partnership for Long-Term Care. Regulations.
Sec. 38a-476. Preexisting condition coverage.
Sec. 38a-476a. Compliance with the Health Insurance Portability and Accountability Act. Guaranteed renewability. Discrimination based on health status, newborns' and mothers' health prohibited. Parity of mental health benefits. Disclosure of information for employers. Construction. Application. Regulations.
Sec. 38a-476b. Standards re psychotropic drug availability in health plans.
Sec. 38a-477. Standardized claim forms. Information necessary for filing a claim. 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. Exhaustion of internal appeal mechanisms. External appeal to commissioner. Fees. Refund of fees. Request for information. 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.
Secs. 38a-479 to 38a-479z.
Sec. 38a-479aa. Preferred provider networks. Definitions. Licensing. Fees. Requirements.
Sec. 38a-479bb. Requirements for managed care organizations that contract with preferred provider networks. Requirements for preferred provider networks.
Sec. 38a-479cc. Duties of a preferred provider network when providing services pursuant to a contract with a managed care organization.
Sec. 38a-479dd. Preferred provider network examination of outstanding amounts. Notice. Commissioner's duties.
Sec. 38a-479ee. Violations. Penalties. Investigations and staffing. Grievances. Referrals from Managed Care Ombudsman.
Sec. 38a-479ff. Adverse action or threat of adverse action against complainant prohibited. Exception. Civil actions by aggrieved persons.
Sec. 38a-479gg. Regulations.
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. Underwriting classifications.
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-490b. Coverage for hearing aids for children twelve and under.
Sec. 38a-490c. Coverage for craniofacial disorders.
Sec. 38a-491. (Formerly Sec. 38-174h). Coverage for services performed by dentists in certain instances.
Sec. 38a-491a. Coverage for in-patient, outpatient or one-day dental services in certain instances.
Sec. 38a-491b. Assignment of benefits to a dentist or oral surgeon.
Sec. 38a-492. (Formerly Sec. 38-174i). Coverage for accidental ingestion or consumption of controlled drugs. Benefits prescribed.
Sec. 38a-492a. Mandatory coverage for hypodermic needles and syringes.
Sec. 38a-492b. Coverage for off-label drug prescriptions.
Sec. 38a-492c. Coverage for low protein modified food products, amino acid modified preparations and specialized formulas.
Sec. 38a-492d. Mandatory coverage for diabetes testing and treatment.
Sec. 38a-492e. Mandatory coverage for diabetes outpatient self-management training.
Sec. 38a-492f. Mandatory coverage for certain prescription drugs removed from formulary.
Sec. 38a-492g. Mandatory coverage for prostate cancer screening.
Sec. 38a-492h. Mandatory coverage for certain Lyme disease treatments.
Sec. 38a-492i. Mandatory coverage for pain management.
Sec. 38a-492j. Mandatory coverage for ostomy-related supplies.
Sec. 38a-492k. Mandatory coverage for colorectal cancer screening.
Sec. 38a-493. (Formerly Sec. 38-174k). Mandatory coverage for home health care. Deductibles. Exception from deductible limits for medical savings accounts, Archer MSAs and health savings accounts.
Sec. 38a-494. (Formerly Sec. 38-174l). Home health care by recognized nonmedical systems.
Sec. 38a-495. (Formerly Sec. 38-174m). Medicare supplement policies. Coverage of home health aid services and mammography. Prescription drug riders.
Sec. 38a-495a. Medicare supplement policies and certificates. Minimum required policy benefits and standards. Regulations.
Sec. 38a-495b. Medicare supplement policies and certificates. Definitions.
Sec. 38a-495c. 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. National Medical Support Notice. 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.
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, chemotherapy and wigs. Mandatory coverage for breast reconstruction after mastectomy.
Sec. 38a-504a. Coverage for certain cancer clinical trials.
Sec. 38a-504b. Cancer clinical trials that are eligible for coverage.
Sec. 38a-504c. Evidence and information re eligibility for cancer clinical trial. No coverage required for otherwise reimbursable costs.
Sec. 38a-504d. Cancer clinical trials: Routine patient care costs.
Sec. 38a-504e. Cancer clinical trials: Billing. Payments. Appeals.
Sec. 38a-504f. Cancer clinical trials: Standardized forms. Time frames for coverage determinations. Appeals. Regulations.
Sec. 38a-504g. Cancer clinical trials: Submission and certification of policy forms.
Sec. 38a-505. (Formerly Sec. 38-378). Insurance Commissioner's powers concerning comprehensive health care plans. Notification to purchasers of policy.
Sec. 38a-506. (Formerly Sec. 38-173). Penalty.
Sec. 38a-507. Coverage for services performed by chiropractors.
Sec. 38a-508. Coverage for adopted children.
Secs. 38a-509 to 38a-511.
Sec. 38a-512. Applicability of statutes to certain major medical expense policies.
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-516b. Coverage for hearing aids for children twelve and under.
Sec. 38a-516c. Coverage for craniofacial disorders.
Sec. 38a-517. Coverage for services performed by dentist in certain instances.
Sec. 38a-517a. Coverage for in-patient, outpatient or one-day dental services in certain instances.
Sec. 38a-517b. Assignment of benefits to a dentist or oral surgeon.
Sec. 38a-518. Coverage for accidental ingestion or consumption of controlled drugs. Benefits prescribed.
Sec. 38a-518a. Mandatory coverage for hypodermic needles and syringes.
Sec. 38a-518b. Coverage for off-label drug prescriptions.
Sec. 38a-518c. Coverage for low protein modified food products, amino acid modified preparations and specialized formulas.
Sec. 38a-518d. Mandatory coverage for diabetes testing and treatment.
Sec. 38a-518e. Mandatory coverage for diabetes outpatient self-management training.
Sec. 38a-518f. Mandatory coverage for certain prescription drugs removed from formulary.
Sec. 38a-518g. Mandatory coverage for prostate cancer screening.
Sec. 38a-518h. Mandatory coverage for certain Lyme disease treatments.
Sec. 38a-518i. Mandatory coverage for pain management.
Sec. 38a-518j. Mandatory coverage for ostomy-related supplies.
Sec. 38a-518k. Mandatory coverage for colorectal cancer screening.
Sec. 38a-519. (Formerly Sec. 38-174j). Offset proviso prohibited in certain policies.
Sec. 38a-520. Mandatory coverage for home health care. Deductibles. Exception from deductible limits for medical savings accounts. Archer MSAs and health savings accounts.
Sec. 38a-521. Home health care by recognized nonmedical systems.
Sec. 38a-522. Medicare supplement policies. Coverage of home health aide service.
Sec. 38a-523. (Formerly Sec. 38-174p). Group hospital or medical insurance coverage for comprehensive rehabilitation services.
Sec. 38a-524. Coverage for occupational therapy. Definitions. Benefits.
Sec. 38a-525. Mandatory coverage for medically necessary ambulance services. Direct payment to ambulance provider.
Sec. 38a-525a. Preauthorization prohibited for certain 9-1-1 emergency calls.
Sec. 38a-526. Mandatory coverage for services of physician assistants and certain nurses.
Sec. 38a-527. Mandatory coverage for partners, sole proprietors and corporate officers for work-related injuries.
Sec. 38a-528. Long-term care policies.
Sec. 38a-529. Mandatory coverage for services provided by the Veterans' Home.
Sec. 38a-530. Mandatory coverage for mammography.
Sec. 38a-530a. Mandatory coverage for breast cancer survivors.
Sec. 38a-530b. Carriers to permit direct access to obstetrician-gynecologist.
Sec. 38a-530c. Mandatory coverage for maternity care. Notice required.
Sec. 38a-530d. Mandatory coverage for mastectomy care. Termination of provider contract prohibited.
Sec. 38a-530e. Mandatory coverage for prescription contraceptives.
Sec. 38a-531. (Formerly Sec. 38-174hh). Mandatory coverage for employees of certain employers. Approval of policy forms.
Sec. 38a-532. (Formerly Sec. 38-262a). Assignment of incidents of ownership under group life, health or accident policy.
Sec. 38a-533. (Formerly Sec. 38-262b). Mandatory coverage for the treatment of medical complications of alcoholism.
Sec. 38a-534. 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, chemotherapy and wigs. Mandatory coverage for breast reconstruction after mastectomy.
Sec. 38a-542a. Cancer clinical trials: Coverage for routine patient care costs.
Sec. 38a-542b. Cancer clinical trials: When eligible for coverage.
Sec. 38a-542c. Cancer clinical trials: Evidence and information re eligibility for. No coverage required for otherwise reimbursable costs.
Sec. 38a-542d. Cancer clinical trials: Routine patient care costs.
Sec. 38a-542e. Cancer clinical trials: Billing. Payments. Appeals.
Sec. 38a-542f. Cancer clinical trials: Standardized forms. Time frames for coverage determinations. Appeals. Regulations.
Sec. 38a-542g. Cancer clinical trials: Submission and certification of policy forms.
Sec. 38a-543. (Formerly Sec. 38-262j). Age discrimination in group insurance coverage prohibited.
Sec. 38a-544. Prescription drug coverage. Mail order pharmacies.
Sec. 38a-545. (Formerly Sec. 38-262k). Group dental health insurance plans. Alternative coverage option.
Sec. 38a-546. (Formerly Sec. 38-379). 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.

PART I
HEALTH INSURANCE: IN GENERAL

      Sec. 38a-469. Definitions. As used in this title, unless the context otherwise requires or a different meaning is specifically prescribed, "health insurance" policy means insurance providing benefits due to illness or injury, resulting in loss of life, loss of earnings, or expenses incurred, and includes the following types of coverage: (1) Basic hospital expense coverage; (2) basic medical-surgical expense coverage; (3) hospital confinement indemnity coverage; (4) major medical expense coverage; (5) disability income protection coverage; (6) accident only coverage; (7) long term care coverage; (8) specified accident coverage; (9) Medicare supplement coverage; (10) limited benefit health coverage; (11) hospital or medical service plan contract; (12) hospital and medical coverage provided to subscribers of a health care center; (13) specified disease coverage.

      (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; (Revisor's note: In 2005 the words "title 38a" were replaced editorially by the Revisors with "this title").

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

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

      (c) The lien shall arise at the time such benefits are paid or such services are rendered. The person or entity furnishing such benefits or services shall serve written notice upon the employee, the insurance company providing workers' compensation benefits or the employer, if self-insured, and the workers' compensation commissioner for the district in which the claim for workers' compensation has been filed, setting forth the nature and extent of the lien allowable under subsection (b). 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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      Sec. 38a-471. (Formerly Sec. 38-174o). Third party prescription programs. Notice of cancellation. Applicability of section. (a) As used in this section, a "third party prescription program" means a system of providing for reimbursement for the cost of drugs or pharmaceutical services under a contractual arrangement or agreement with a provider of such drugs or services. Such programs shall include, but not be limited to, employee benefit plans under which a consumer receives prescription drugs or pharmaceutical services and such drugs or services are paid for in part by an agent of the consumer's employer or others. An "administrator" means the program administrator of a third party prescription program.

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

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

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

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

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

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

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

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

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

      (P.A. 81-455, S. 1-8.)

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

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

      (b) Whenever there is in existence a contract by an insurer for payment to, or on behalf of, an applicant or recipient of medical assistance under the 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; P.A. 04-76, S. 36.)

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

      Annotation to former section 38-174a:

      Subsec. (b):

      Cited. 219 C. 439, 442.

      Annotation to present section:

      Cited. 219 C. 439, 442.

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

      (P.A. 95-199, S. 3.)

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

      (P.A. 95-199, S. 4.)

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      Sec. 38a-472c. Dental policies. Estimate of reimbursement. For any policy delivered, issued for delivery, renewed, amended or continued in this state on or after October 1, 2004, that provides coverage for inpatient or outpatient dental services only, the person who issues the policy shall provide the insured or a licensed dentist acting on behalf of the insured, upon request, an estimate of reimbursement under the policy with respect to specific dental procedure codes ordered or recommended for the insured by a licensed dentist, except that the actual reimbursement may be adjusted based on factors such as the insured's eligibility, plan design, utilization of benefits and the actual claim submitted.

      (P.A. 04-125, S. 1.)

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      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.

      (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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      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.

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

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

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

      See Sec. 17b-251 re outreach program.

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

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

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

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

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

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

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

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

      (b) (1) No group health insurance plan or insurance arrangement 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 their policies or contracts, for the preexisting conditions of any newly insured individual who was previously covered for such preexisting condition under the terms of the individual's preceding qualifying coverage, provided the preceding coverage was continuous to a date less than one hundred twenty days prior to the effective date of the new coverage, exclusive of any applicable waiting period, except in the case of a newly insured group member whose previous coverage was terminated due to an involuntary loss of employment, the preceding coverage must have been continuous to a date not more than one hundred fifty days prior to the effective date of the new coverage, exclusive of any applicable waiting period, provided such newly insured group member or dependent applies for such succeeding coverage within thirty days of the member's or dependent's initial eligibility.

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

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

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

      (g) 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; P.A. 02-24, S. 5.)

      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; P.A. 02-24 substituted "their" for "its" in Subsec. (c).

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

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

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

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

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

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

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

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

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

      (P.A. 01-171, S. 17.)

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

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

Item NumberItem Description
1aInsured's identification number
2Patient's name
3Patient's birth date and sex
4Insured's name
10aPatient's condition - employment
10bPatient's condition - auto accident
10cPatient's condition - other accident
11Insured's policy group number (if provided on identification card)
11dIs there another health benefit plan?
17aIdentification number of referring physician (if required by insurer)
21Diagnosis
24ADates of service
24BPlace of service
24DProcedures, services or supplies
24EDiagnosis code
24FCharges
25Federal tax identification number
28Total charge
31Signature of physician or supplier with date
33Physician's, supplier's billing name, address, zip code & telephone number

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

Item NumberItem Description
1Provider name and address
5Federal tax identification number
6Statement covers period
12Patient name
14Patient's birth date
15Patient's sex
17Admission date
18Admission hour
19Type of admission
21Discharge hour
42Revenue codes
43Revenue description
44HCPCS/CPT4 codes
45Service date
46Service units
47Total charges by revenue code
50Payer identification
51Provider number
58Insured's name
60Patient's identification number (policy number and/or Social Security number)
62Insurance group number (if on identification card)
67Principal diagnosis code
76Admitting diagnosis code
80Principle procedure code and date
81Other procedures code and date
82Attending physician's identification number

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

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

      History: P.A. 03-57 substituted "Health Care Financing Administration UB-92 health insurance claim form" for "UB-82" in Subsec. (a), added new Subsecs. (b) and (c) re information on HCFA1500 claim form and UB-92 claim form, respectively, redesignated existing Subsec. (b) as Subsec. (d) and made technical changes therein.

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PART Ia
HEALTH INSURANCE: MANAGED CARE

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

      (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 383c, 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.

      (6) "Preferred provider network" means a preferred provider network, as defined in section 38a-479aa.

      (7) "Utilization review" means utilization review, as defined in section 38a-226.

      (8) "Utilization review company" means a utilization review company, as defined in section 38a-226.

      (P.A. 97-99, S. 1; P.A. 03-169, S. 10; P.A. 04-125, S. 2.)

      History: P.A. 03-169 added Subdivs. (6) to (8), defining "preferred provider network", "utilization review" and "utilization review company"; P.A. 04-125 redefined "provider" in Subdiv. (4) to reference "chapter 383c".

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      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 38a-226 to 38a-226d, inclusive, 38a-478 to 38a-478u, inclusive, 38a-479aa and 38a-993. The report shall include: (1) A summary of the quality assurance plans submitted by managed care organizations pursuant to section 38a-478c along with suggested changes to improve such plans; (2) suggested modifications to the consumer report card developed under the provisions of section 38a-478l; (3) a summary of the commissioner's procedures and activities in conducting market conduct examinations of utilization review companies and preferred provider networks, including, but not limited to: (A) The number of desk and field audits completed during the previous calendar year; (B) a summary of findings of the desk and field audits, including any recommendations made for improvements or modifications; (C) a description of complaints concerning managed care companies, and any preferred provider network that provides services to enrollees on behalf of the managed care organization, including a summary and analysis of any trends or similarities found in the managed care complaints filed by enrollees; (4) a summary of the complaints 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 or any preferred provider network that provides services to enrollees on behalf of the managed care organization; and (6) a summary of the issues discussed related to health care or managed care organizations at the Insurance Department's quarterly forums throughout the state.

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

      History: June 18 Sp. Sess. P.A. 97-8 changed reporting date from January 15, 1999, to March 1, 1999, and in Subdiv. (3)(C) changed "complaints" to "managed care complaints", effective July 1, 1997; P.A. 99-284 deleted obsolete reference to Sec. 38a-514a, effective January 1, 2000; P.A. 00-196 made a technical change; June Sp. Sess. P.A. 01-4 replaced reference to Sec. 19a-647 with reference to Sec. 38a-479aa; P.A. 03-169 added provisions re preferred provider networks in Subdivs. (3) and (5).

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      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 38a-226 to 38a-226d, inclusive, 38a-478 to 38a-478u, inclusive, 38a-479aa and 38a-993 shall pay a late fee of one hundred dollars per day for each day from the due date of such data, reports or information to the date of filing. Each managed care organization that files incomplete data, reports or information shall be so informed by the commissioner, shall be given a date by which to remedy such incomplete filing and shall pay said late fee commencing from the new due date.

      (b) On June 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 38a-226 to 38a-226d, inclusive, 38a-478 to 38a-478u, inclusive, 38a-479aa and 38a-993.

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

      History: P.A. 99-284 deleted obsolete references to Sec. 38a-514a, effective January 1, 2000; P.A. 00-196 made a technical change in Subsec. (b); June Sp. Sess. P.A. 01-4 replaced references to Sec. 19a-647 with references to Sec. 38a-479aa.

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      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:

      (1) A report on its quality assurance plan that includes, but is not limited to, information on complaints related to providers and quality of care, on decisions related to patient requests for coverage and on prior authorization statistics. Statistical information shall be submitted in a manner permitting comparison across plans and shall include, but not be limited to: (A) The ratio of the number of complaints received to the number of enrollees; (B) a summary of the complaints received related to providers and delivery of care or services and the action taken on the complaint; (C) the ratio of the number of prior authorizations denied to the number of prior authorizations requested; (D) the number of utilization review determinations made by or on behalf of a managed care organization not to certify an admission, service, procedure or extension of stay, and the denials upheld and reversed on appeal within the managed care organization's utilization review procedure; (E) the percentage of those employers or groups that renew their contracts within the previous twelve months; and (F) notwithstanding the provisions of this subsection, on or before July 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 managed care organization and preferred provider networks in this state, and the managed care organization and participating providers in this state and, upon the commissioner's request, a copy of any individual contracts between such parties, provided the contract may withhold or redact proprietary fee schedule information.

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

      (4) Such information as the commissioner deems necessary to complete the consumer report card required pursuant to section 38a-478l. Such information may include, but need not be limited to: (A) The organization's characteristics, including its model, its profit or nonprofit status, its address and telephone number, the length of time it has been licensed in this and any other state, its number of enrollees and whether it has received any national or regional accreditation; (B) a summary of the information required by subdivision (3) of this section, including any change in a plan's rates over the prior three years, its 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, the number and nature of participating preferred provider networks and the distribution and number of hospitals, by county; (D) utilization review information, including the name or source of any established medical protocols and the utilization review standards; (E) medical management information, including the provider-to-patient ratio by primary care provider and 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; P.A. 03-169, S. 12.)

      History: P.A. 98-27 amended Subpara. (a)(1)(F) to add "Notwithstanding the provisions of this subsection, on or before July 1, 1998, and annually thereafter" re required data; P.A. 03-169 amended Subsec. (a) to reword Subdiv. (1)(D) re utilization review determinations, to add in Subdivs. (2) and (3) reference to preferred provider networks, to substitute "required" for "he is required to develop and distribute" in Subdiv. (4) and to add "the number and nature of participating preferred provider networks" in Subpara. (C), and make conforming changes.

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      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.

      (P.A. 97-99, S. 5.)

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

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

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

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

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

      (P.A. 97-99, S. 7.)

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      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.

      (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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      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.

      (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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      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.

      (P.A. 97-99, S. 10.)

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

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

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

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      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.

      (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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      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.

      (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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      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:

      (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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      Sec. 38a-478n. Exhaustion of internal appeal mechanisms. External appeal to commissioner. Fees. Refund of fees. Request for information. Public education outreach program. (a) 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 the denial of a claim based on medical necessity or a determination not to certify an admission, service, procedure or extension of stay, regardless of whether such determination was made before, during or after the admission, service, procedure or extension of stay, may appeal such denial or determination to the commissioner.

      (b) (1) To appeal a denial or determination pursuant to this section an enrollee or any provider acting on behalf of an enrollee shall, not later than thirty days after receiving final written notice of the denial or 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 the commissioner and shall include the filing fee set forth in subdivision (2) of this subsection and a general release executed by the enrollee for all medical records pertinent to the appeal. The managed care organization or utilization review company named in the appeal shall also pay to the commissioner the filing fee set forth in subdivision (2) of this subsection.

      (2) The filing fee shall be twenty-five dollars and shall be deposited in the Insurance Fund established in section 38a-52a. If the commissioner finds that an enrollee is indigent or unable to pay the fee, the commissioner shall waive the enrollee's fee. The commissioner shall refund any paid filing fee to (A) the managed care organization or utilization review company if the appeal is not accepted for full review, or (B) the prevailing party upon completion of a full review pursuant to this section.

      (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 the appeal 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 why the appeal was not accepted for full review.

      (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) (1) Not later than five business days after receiving a written request from the commissioner, enrollee or any provider acting on behalf of an enrollee with the enrollee's consent, a managed care organization whose enrollee is the subject of an appeal shall provide to the commissioner, enrollee or any provider acting on behalf of an enrollee with the enrollee's consent, written verification of whether the enrollee's managed care plan is fully insured, self-funded, or otherwise funded. If the plan is a fully insured plan or a self-insured governmental plan, the managed care organization shall send: (A) Written certification to the commissioner or reviewing entity, as determined by the commissioner, that the benefit or service subject to the appeal is a covered benefit or service; (B) a copy of the entire policy or contract between the enrollee and the managed care organization, except that with respect to a self-insured governmental plan, (i) the managed care organization shall notify the plan sponsor, and (ii) the plan sponsor shall send, or require the managed care organization to send, such copy; or (C) written certification that the policy or contract is accessible to the review entity electronically and clear and simple instructions on how to electronically access the policy.

      (2) Failure of the managed care organization to provide information or notify the plan sponsor in accordance with subdivision (1) of this subsection within said five-business-day period or before the expiration of the thirty-day period for appeals set forth in subdivision (1) of subsection (b) of this section, whichever is later as determined by the commissioner, shall (A) create a presumption on the review entity, solely for purposes of accepting an appeal and conducting the review pursuant to subdivision (4) of subsection (b) of this section, that the benefit or service is a covered benefit under the applicable policy or contract, except that such presumption shall not be construed as creating or authorizing benefits or services in excess of those that are provided for in the enrollee's policy or contract, and (B) entitle the commissioner to require the managed care organization from whom the enrollee is appealing a medical necessity determination to reimburse the department for the expenses related to the appeal, including, but not limited to, expenses incurred by the review entity.

      (e) The commissioner shall accept the decision of the review entity and the decision of the commissioner shall be binding.

      (f) 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; P.A. 03-278, S. 94; P.A. 04-157, S. 1.)

      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; P.A. 03-278 made a technical change in Subsec. (b)(2), effective July 9, 2003; P.A. 04-157 amended Subsec. (a) to include appeals for "the denial of a claim based on medical necessity" and add "regardless of whether such determination was made before, during or after the admission, service, procedure or extension of stay", amended Subsec. (b)(1) to require managed care organization or utilization review company named in the appeal to pay filing fee, amended Subsec. (b)(2) to require commissioner to refund any paid filing fee if the appeal is not accepted or upon completion of full review, inserted new Subsec. (d) re written request for information and failure to provide information or notify the plan sponsor, redesignated existing Subsecs. (d) and (e) as new Subsecs. (e) and (f), respectively, and made conforming and technical changes.

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

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

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

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

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      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.

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

      (P.A. 97-99, S. 25.)

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

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

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

      (d) The Insurance Commissioner, 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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      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.

      (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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      Sec. 38a-478t. Commissioner of Public Health to receive data. The Commissioner of Public Health may request and shall receive any data, report or information filed with the Insurance Commissioner pursuant to the provisions of sections 38a-226 to 38a-226d, inclusive, 38a-478 to 38a-478u, inclusive, 38a-479aa and 38a-993.

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

      History: P.A. 99-284 deleted obsolete reference to Sec. 38a-514a, effective January 1, 2000; June Sp. Sess. P.A. 01-4 replaced reference to Sec. 19a-647 with reference to Sec. 38a-479aa.

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      Sec. 38a-478u. Regulations. The Insurance Commissioner may adopt regulations in accordance with the provisions of chapter 54 to implement the provisions of sections 38a-226 to 38a-226d, inclusive, 38a-478 to 38a-478u, inclusive, 38a-479aa and 38a-993.

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

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

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

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

      (P.A. 99-284, S. 31.)

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

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PART Ib
HEALTH INSURANCE: PREFERRED PROVIDER NETWORKS

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

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

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

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

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

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

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

      (7) "Preferred provider network" means a person, which is not a managed care organization, but which pays claims for the delivery of health care services, accepts financial risk for the delivery of health care services and establishes, operates or maintains an arrangement or contract with providers relating to (A) the health care services rendered by the providers, and (B) the amounts to be paid to the providers for such services. "Preferred provider network" does not include a workers' compensation preferred provider organization established pursuant to section 31-279-10 of the regulations of Connecticut state agencies or an independent practice association or physician hospital organization whose primary function is to contract with insurers and provide services to providers;

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

      (9) "Commissioner" means the Insurance Commissioner.

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

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

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

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

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

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

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

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

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

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

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

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

      (m) Each utilization review determination made by or on behalf of a preferred provider network shall be made in accordance with sections 38a-226 to 38a-226d, inclusive, except that any initial appeal of a determination not to certify an admission, service, procedure or extension of stay shall be conducted in accordance with subdivision (7) of subsection (a) of section 38a-226c, and any subsequent appeal shall be referred to the managed care organization on whose behalf the preferred provider network provides services. The managed care organization shall conduct the subsequent appeal in accordance with said subdivision.

      (June Sp. Sess. P.A. 01-4, S. 21; P.A. 03-169, S. 1.)

      History: P.A. 03-169 amended Subsec. (a) to substantially revise definitions, amended Subsec. (b) to require licensure before May 1, 2004, or May 1, 2005, for certain activities and to revise filing requirements, amended Subsec. (d) to make technical changes, amended Subsec. (e) to allow the commissioner to inspect books and records, and added new Subsecs. (f) to (m), inclusive, re requirements for preferred provider networks.

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

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

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

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

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

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

      (4) Any other information the commissioner may require.

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

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

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

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

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

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

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

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

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

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

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

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

      (12) A provision that the preferred provider network shall ensure that utilization review determinations are made in accordance with sections 38a-226 to 38a-226d, inclusive, except that any initial appeal of a determination not to certify an admission, service, procedure or extension of stay shall be made in accordance with subdivision (7) of subsection (a) of section 38a-226c. In cases where an appeal to reverse a determination not to certify is unsuccessful, the preferred provider network shall refer the case to the managed care organization which shall conduct the subsequent appeal, if any, in accordance with said subdivision.

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

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

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

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

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

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

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

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

      (2) If the managed care organization determines that the preferred provider network's provider network is not adequate and must be increased, the managed care organization shall provide written notice of the determination to the commissioner. Such notice shall describe (1) any plan in place for the preferred provider network to increase its provider network, and (2) the managed care organization's contingency plan in the event the preferred provider network does not satisfactorily increase its provider network.

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

      (P.A. 03-169, S. 2.)

      History: P.A. 03-169 effective May 1, 2004.

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

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

      (P.A. 03-169, S. 3.)

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

      (P.A. 03-169, S. 4.)

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      Sec. 38a-479ee. Violations. Penalties. Investigations and staffing. Grievances. Referrals from Managed Care Ombudsman. (a) If the Insurance Commissioner determines that a preferred provider network or managed care organization, or both, has not complied with any applicable provision of this part, sections 38a-226 to 38a-226d, inclusive, or sections 38a-815 to 38a-819, inclusive, the commissioner may (1) order the preferred provider network or managed care organization, or both if both have not complied, to cease and desist all operations in violation of this part or said sections; (2) terminate or suspend the preferred provider network's license; (3) institute a corrective action against the preferred provider network or managed care organization, or both if both have not complied; (4) order the payment of a civil penalty by the preferred provider network or managed care organization, or both if both have not complied, of not more than one thousand dollars for each and every act or violation; (5) order the payment of such reasonable expenses as may be necessary to compensate the commissioner in conjunction with any proceedings held to investigate or enforce violations of this part, sections 38a-226 to 38a-226d, inclusive, or sections 38a-815 to 38a-819, inclusive; and (6) use any of the commissioner's other enforcement powers to obtain compliance with this part, sections 38a-226 to 38a-226d, inclusive, or sections 38a-815 to 38a-819, inclusive. The commissioner may hold a hearing concerning any matter governed by this part, sections 38a-226 to 38a-226d, inclusive, or sections 38a-815 to 38a-819, inclusive, in accordance with section 38a-16. Subject to the same confidentiality and liability protections set forth in subsections (c) and (k) of section 38a-14, the commissioner may engage the services of attorneys, appraisers, independent actuaries, independent certified public accountants or other professionals and specialists to assist the commissioner in conducting an investigation under this section, the cost of which shall be borne by the managed care organization or preferred provider network, or both, that is the subject of the investigation.

      (b) If a preferred provider network fails to comply with any applicable provision of this part, sections 38a-226 to 38a-226d, inclusive, or sections 38a-815 to 38a-819, inclusive, the commissioner may assign or require the preferred provider network to assign its rights and obligations under any contract with participating providers in order to ensure that covered benefits are provided.

      (c) The commissioner shall receive and investigate (1) any grievance filed against a preferred provider network or managed care organization, or both, by an enrollee or an enrollee's designee concerning matters governed by this part, sections 38a-226 to 38a-226d, inclusive, or sections 38a-815 to 38a-819, inclusive, or (2) any referral from the Office of Managed Care Ombudsman pursuant to section 38a-1041. The commissioner shall code, track and review such grievances and referrals. The preferred provider network or managed care organization, or both, shall provide the commissioner with all information necessary for the commissioner to investigate such grievances and referrals. The information collected by the commissioner pursuant to this section shall be maintained as confidential and shall not be disclosed to any person except (A) to the extent necessary to carry out the purposes of this part, sections 38a-226 to 38a-226d, inclusive, or sections 38a-815 to 38a-819, inclusive, (B) as allowed under this title, (C) to the Managed Care Ombudsman and (D) information concerning the nature of any grievance or referral and the commissioner's final determination shall be a public record, as defined in section 1-200, provided no personal information, as defined in section 38a-975, shall be disclosed. The commissioner shall report to the Managed Care Ombudsman on the resolution of any matter referred to the commissioner by the Managed Care Ombudsman.

      (P.A. 03-169, S. 5.)

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      Sec. 38a-479ff. Adverse action or threat of adverse action against complainant prohibited. Exception. Civil actions by aggrieved persons. No health insurer, health care center, utilization review company, as defined in section 38a-226, or preferred provider network, as defined in section 38a-479aa, shall take or threaten to take any adverse personnel or coverage-related action against any enrollee, provider or employee in retaliation for such enrollee, provider or employee (1) filing a complaint with the Insurance Commissioner or the Office of Managed Care Ombudsman, or (2) disclosing information to the Insurance Commissioner concerning any violation of this part, sections 38a-226 to 38a-226d, inclusive, or sections 38a-815 to 38a-819, inclusive, unless such disclosure violates the provisions of chapter 705 or the privacy provisions of the federal Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191) (HIPAA), as amended from time to time, or regulations adopted thereunder. Any enrollee, provider or employee who is aggrieved by a violation of this section may bring a civil action in the Superior Court to recover damages and attorneys' fees and costs.

      (P.A. 03-169, S. 6.)

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

      (P.A. 03-169, S. 7.)

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PART II
INDIVIDUAL HEALTH INSURANCE

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

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

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

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

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      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. Underwriting classifications. (a) No individual health insurance policy shall be delivered or issued for delivery to any person in this state, nor shall any application, rider or endorsement be used in connection therewith, until a copy of the form thereof and of the classification of risks and the premium rates have been filed with the commissioner. The commissioner shall adopt regulations in accordance with the provisions of chapter 54, establishing a procedure for review of such policies. The commissioner shall disapprove the use of such form at any time if it does not comply with the requirements of law, or if it contains a provision or provisions which are unfair or deceptive or which encourage misrepresentation of the policy. The commissioner shall notify, in writing, the insurer which has filed any such form of his disapproval, specifying his reasons therefor, and ordering that no such insurer shall deliver or issue for delivery to any person in this state a policy on or containing such form. The provisions of section 38a-19 shall apply to such orders.

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

      (c) No insurance company, fraternal benefit society, hospital service corporation, medical service corporation, health care center or 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.

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

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

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

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

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

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

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

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

      (f) For the purposes of this section:

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

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

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

      (h) No insurance company, fraternal benefit society, hospital service corporation, medical service corporation, health care center or other entity which delivers, issues for delivery, amends, renews or continues an individual health insurance policy in this state on or after October 1, 2003, may (1) move an insured individual from a standard underwriting classification to a substandard underwriting classification after the policy is issued; or (2) increase premium rates due to the claim experience or health status of an individual who is insured under the policy, except that the entity may increase premium rates for all individuals in an underwriting classification due to the claim experience or health status of the underwriting classification as a whole.

      (1949 Rev., S. 6177; 1951, S. 2835d; 1967, P.A. 437, S. 1; P.A. 78-280, S. 6, 127; P.A. 88-230, S. 1, 12; 88-326, S. 4; P.A. 90-243, S. 72; P.A. 91-311; P.A. 93-390, S. 5, 8; P.A. 96-51, S. 2; P.A. 03-119, S. 1.)

      History: 1967 act added Subsec. (b) re effective date of rates and rate standards; P.A. 78-280 replaced "Hartford county" with "judicial district of Hartford-New Britain" in Subsec. (a); P.A. 88-230 proposed to replace reference to "judicial district of Hartford-New Britain" with "judicial district of Hartford", effective September 1, 1991, but said reference was deleted by P.A. 88-326; P.A. 88-326 required the commissioner to adopt regulations establishing a procedure for policy review and rephrased existing provisions; P.A. 90-243 substituted reference to "individual health insurance policy" for references to insurance against loss from sickness, bodily injury or accidental death; Sec. 38-165 transferred to Sec. 38a-481 in 1991; P.A. 91-311 amended Subsec. (b) to exclude Medicare supplement policy rates unless filed in accordance with Sec. 38a-474, added a new Subsec. (c) re filing of the required loss ratio guarantee form to preclude the claim that a particular policy has excessive rates and added the discretionary authority for the commissioner to adopt regulations re the terms of the loss ratio guarantee, added a new Subsec. (d) re premium rates if filed with a loss ratio guarantee and outlining the minimum requirements of a loss ratio guarantee in order to meet the commissioner's approval, the refund procedure for Connecticut policyholders and the procedures by which a policy form can be withdrawn and added Subsec. (e) defining "loss ratio" and "experience period"; P.A. 93-390 inserted new Subsec. (c) prohibiting the incorporation of factors for age, gender, previous claim or medical condition history into the insurer's rate schedule and relettered the remaining Subsecs. and internal references accordingly, effective January 1, 1994; P.A. 96-51 added Subsec. (g) to permit optional life insurance riders; P.A. 03-119 added Subsec. (h) re underwriting classifications.

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

      Annotation to former section 38-165:

      Cited. 186 C. 507, 509.

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

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

      History: 1972 act changed maximum insurable age of children in Subsec. (a) (3) from nineteen to eighteen, reflecting changed age of majority; P.A. 90-243 added reference to "individual health insurance" and deleted former Subsec. (b); Sec. 38-166 transferred to Sec. 38a-482 in 1991.

      Annotations to former section 38-166:

      Cited. 214 C. 303, 309, 310.

      Subsec. (a):

      Subdiv. (5) cited. 214 C. 303, 309.

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

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

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

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

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

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

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

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

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

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

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

      (11) A provision as follows: "LEGAL ACTIONS: No action at law or in equity shall be brought to recover on this policy prior to the expiration of sixty days after written proof of loss has been furnished in accordance with the requirements of this policy. No such action shall be brought after the expiration of three years after the time written proof of loss is required to be furnished."

      (12) A provision as follows: "CHANGE OF BENEFICIARY: Unless the insured makes an irrevocable designation of beneficiary, the right to change of beneficiary is reserved to the insured and the consent of the beneficiary or beneficiaries shall not be requisite to surrender or assignment of this policy or to any change of beneficiary or beneficiaries, or to any other changes in this policy." The first clause of this provision, relating to the irrevocable designation of beneficiary, may be omitted at the insurer's option.

      (b) Except as provided in subsection (c) of this section, no such policy delivered or issued for delivery to any person in this state shall contain provisions respecting the matters set forth below unless such provisions are in the words in which the same appear in this section; provided the insurer may, at its option, use in lieu of any such provision a corresponding provision of different wording approved by the commissioner which is not less favorable in any respect to the insured or the beneficiary. Any such provision contained in the policy shall be preceded individually by the appropriate caption appearing in this subsection or, at the option of the insurer, by such appropriate individual or group captions or subcaptions as the commissioner may approve.

      (1) A provision as follows: "CHANGE OF OCCUPATION: If the insured be injured or contract sickness after having changed his occupation to one classified by the insurer as more hazardous than that stated in his policy or while doing for compensation anything pertaining to an occupation so classified, the insurer will pay only such portion of the indemnities provided in this policy as the premium paid would have purchased at the rates and within the limits fixed by the insurer for such more hazardous occupation. If the insured changes his occupation to one classified by the insurer as less hazardous than that stated in this policy, the insurer, upon receipt of proof of such change of occupation, will reduce the premium rate accordingly, and will return the excess pro-rata unearned premium from the date of change of occupation or from the policy anniversary date immediately preceding receipt of such proof, whichever is the more recent. In applying this provision, the classification of occupational risk and the premium rates shall be such as have been last filed by the insurer prior to the occurrence of the loss for which the insurer is liable or prior to date of proof of change in occupation with the state official having supervision of insurance in the state where the insured resided at the time this policy was issued; but if such filing was not required, then the classification of occupational risk and the premium rates shall be those last made effective by the insurer in such state prior to the occurrence of the loss or prior to the date of proof of change in occupation."

      (2) A provision as follows: "MISSTATEMENT OF AGE: If the age of the insured has been misstated, all amounts payable under this policy shall be such as the premium paid would have purchased at the correct age."

      (3) A provision in accordance with subparagraph (i) or (ii) of this subdivision as follows: (i) "OTHER INSURANCE IN THIS INSURER: If an accident or sickness or accident and sickness policy or policies previously issued by the insurer to the insured be in force concurrently herewith, making the aggregate indemnity for .... (insert type of coverage or coverages) in excess of $.... (insert maximum limit of indemnity or for such excess shall be returned to the insured or his estate"; or, (ii) "OTHER INSURANCE IN THIS INSURER: Insurance effective at any one time on the insured under a like policy or policies in this insurer is limited to the one such policy elected by the insured, his beneficiary or his estate, as the case may be, and the insurer will return all premiums paid for all other such policies."

      (4) A provision as follows: "INSURANCE WITH OTHER INSURERS: If there be other valid coverage, not with this insurer, providing benefits for the same loss on a provision of service basis or on an expense incurred basis and of which this insurer has not been given written notice prior to the occurrence or commencement of loss, the only liability under any expense incurred coverage of this policy shall be for such proportion of the loss as the amount which would otherwise have been payable hereunder plus the total of the like amounts under all such other valid coverages for the same loss of which this insurer had notice bears to the total like amounts under all valid coverages for such loss, and for the return of such portion of the premiums paid as shall exceed the pro-rata portion for the amount so determined. For the purpose of applying this provision when other coverage is on a provision of service basis, the "like amount" of such other coverage shall be taken as the amount which the services rendered would have cost in the absence of such coverage." If the foregoing policy provision is included in a policy which also contains the policy provisions specified in subdivision (5) of this subsection, there shall be added to the caption of the foregoing provision the phrase "- EXPENSE INCURRED BENEFITS". The insurer may, at its option, include in this provision a definition of "other valid coverage", approved as to form by the commissioner, which definition shall be limited in subject matter to coverage provided by organizations subject to regulation by insurance law or by insurance authorities of this or any other state of the United States or any province of Canada, and by hospital or medical service organizations, and to any other coverage the inclusion of which may be approved by the commissioner. In the absence of such definition, such terms shall not include group insurance, automobile medical payments insurance, or coverage provided by hospital or medical service organizations or by union welfare plans or employer or employee benefit organizations. For the purpose of applying the foregoing policy provision with respect to any insured, any amount of benefit provided for such insured pursuant to any compulsory benefit statute, including any workers' compensation or employer's liability statute, whether provided by a governmental agency or otherwise, shall in all cases be deemed to be "other valid coverage" of which the insurer has had notice. In applying the foregoing policy provision no third party liability coverage shall be included as "other valid coverage".

      (5) A provision as follows: "INSURANCE WITH OTHER INSURERS: If there be other valid coverage, not with this insurer, providing benefits for the same loss on other than an expense incurred basis and of which this insurer has not been given written notice prior to the occurrence or commencement of loss, the only liability for such benefits under this policy shall be for such proportion of the indemnities otherwise provided hereunder for such loss as the like indemnities of which the insurer had notice (including the indemnities under this policy) bear to the total amount of all like indemnities for such loss, and for the return of such portion of the premium paid as shall exceed the pro-rata portion for the indemnities thus determined." If the foregoing policy provision is included in a policy which also contains the policy provision specified in subdivision (4) of this subsection, there shall be added to the caption of the foregoing provision the phrase "- OTHER BENEFITS". The insurer may, at its option, include in this provision a definition of "other valid coverage", approved as to form by the commissioner, which definition shall be limited in subject matter to coverage provided by organizations subject to regulation by insurance law or by insurance authorities of this or any other state of the United States or any province of Canada, and to any other coverage the inclusion of which may be approved by the commissioner. In the absence of such definition, such term shall not include group insurance, or benefits provided by union welfare plans or by employer or employee benefit organizations. For the purpose of applying the foregoing policy provision with respect to any insured, any amount of benefit provided for such insured pursuant to any compulsory benefit statute including any workers' compensation or employer's liability statute, whether provided by a governmental agency or otherwise shall in all cases be deemed to be "other valid coverage" of which the insurer has had notice. In applying the foregoing policy provision no third party liability coverage shall be included as "other valid coverage".

      (6) A provision as follows: "RELATION OF EARNINGS TO INSURANCE: If the total monthly amount of loss of time benefits promised for the same loss under all valid loss of time coverage upon the insured, whether payable on a weekly or monthly basis, shall exceed the monthly earnings of the insured at the time disability commenced or his average monthly earnings for the period of two years immediately preceding a disability for which claim is made, whichever is the greater, the insurer will be liable only for such proportionate amount of such benefits under this policy as the amount of such monthly earnings or such average monthly earnings of the insured bears to the total amount of monthly benefits for the same loss under all such coverage upon the insured at the time such disability commences and for the return of such part of the premiums paid during such two years as shall exceed the pro-rata amount of the premiums for the benefits actually paid hereunder; but this shall not operate to reduce the total monthly amount of benefits payable under all such coverage upon the insured below the sum of two hundred dollars or the sum of the monthly benefits specified in such coverages, whichever is the lesser, nor shall it operate to reduce benefits other than those payable for loss of time." The foregoing policy provision may be inserted only in a policy which the insured has the right to continue in force subject to its terms by the timely payment of premiums (1) until at least age fifty or (2), in the case of a policy issued after age forty-four, for at least five years from its date of issue. The insurer may, at its option, include in this provision a definition of "valid loss of time coverage", approved as to form by the commissioner, which definition shall be limited in subject matter to coverage provided by governmental agencies or by organizations subject to regulation by insurance law or by insurance authorities of this or any other state of the United States or any province of Canada, or to any other coverage the inclusion of which may be approved by the commissioner or any combination of such coverages. In the absence of such definition such term shall not include any coverage provided for such insured pursuant to any compulsory benefit statute, including any workers' compensation or employer's liability statute, or benefits provided by union welfare plans or by employer or employee benefit organizations.

      (7) A provision as follows: "UNPAID PREMIUM: Upon the payment of a claim under this policy, any premium then due and unpaid or covered by any note or written order may be deducted therefrom."

      (8) A provision as follows: "CANCELLATION: The insurer may cancel this policy at any time by written notice delivered to the insured and to any dependents who were listed on the application and any subsequent revisions thereto, or mailed to their last address as shown by the records of the insurer, stating when, not less than five days thereafter, such cancellation shall be effective; and after the policy has been continued beyond its original term the insured may cancel this policy at any time by written notice delivered or mailed to the insurer, effective upon receipt or on such later date as may be specified in such notice. In the event of cancellation, the insurer will return promptly the unearned portion of any premium paid. If the insured cancels, the earned premium shall be computed by the use of the short-rate table last filed with the state official having supervision of insurance in the state where the insured resided when the policy was issued. If the insurer cancels, the earned premium shall be computed pro-rata. Cancellation shall be without prejudice to any claim originating prior to the effective date of cancellation."

      (9) A provision as follows: "CONFORMITY WITH STATE STATUTES: Any provision of this policy which, on its effective date, is in conflict with the statutes of the state in which the insured resides on such date is hereby amended to conform to the minimum requirements of such statutes."

      (c) If any provision of this section is in whole or in part inapplicable to or inconsistent with the coverage provided by a particular form of policy, the insurer, with the approval of the commissioner, shall omit from such policy any inapplicable provision or part of a provision, and shall modify any inconsistent provision or part of the provision in such manner as to make the provision as contained in the policy consistent with the coverage provided by the policy.

      (d) The provisions specified in subsections (a) and (b) of this section, or any corresponding provisions which are used in lieu thereof in accordance with said subsections, shall be printed in the consecutive order of the provisions in such subsections or, at the option of the insurer, any such provision may appear as a unit in any part of the policy, with other provisions to which it may be logically related, provided the resulting policy shall not be in whole or in part unintelligible, uncertain, ambiguous, abstruse or likely to mislead a person to whom the policy is offered, delivered or issued.

      (e) The word "insured", as used in sections 38a-481 to 38a-488, inclusive, shall not be construed as preventing a person other than the insured with a proper insurable interest from making application for and owning a policy covering the insured or from being entitled under such a policy to any indemnities, benefits and rights provided therein.

      (f) (1) Any policy of a foreign or alien insurer, when delivered or issued for delivery to any person in this state, may contain any provision which is not less favorable to the insured or the beneficiary than the provisions of sections 38a-481 to 38a-488, inclusive, and which is prescribed or required by the law of the state under which the insurer is organized.

      (2) Any policy of a domestic insurer may, when issued for delivery in any other state or country, contain any provision permitted or required by the laws of such other state or country.

      (g) The commissioner may make such reasonable rules and regulations concerning the procedure for the filing or submission of policies subject to sections 38a-481 to 38a-488, inclusive, as are necessary, proper or advisable to the administration of said sections. This provision shall not abridge any other authority granted the commissioner by law.

      (1949 Rev., S. 6179, 6180, 6186; Apps. B, C; 1951, S. 2837d; 1971, P.A. 267; P.A. 79-376, S. 58; P.A. 90-243, S. 74; P.A. 95-40.)

      History: 1971 act replaced previous provisions re "time limit on defenses" which had detailed voidance of policy because of misstatements on application with provision stating that policy is uncontestable except for premium nonpayment after it is in force for two years; P.A. 79-376 substituted "workers' compensation" for "workmen's compensation" where appearing; P.A. 90-243 added reference to "an individual health insurance" policy; Sec. 38-167 transferred to Sec. 38a-483 in 1991; P.A. 95-40 added requirement to Subsec. (b)(8) that written notice be delivered not only to the insured but also to any dependents listed on the application and any subsequent revisions thereto; (Revisor's note: When P.A. 95-40, which amended Subsec. (b)(8) concerning "CANCELLATION", was incorporated into the section by the Revisors, the unamended text of Subsec. (b)(8) was inadvertently moved to and replaced the then existing Subsec. (a)(8) concerning "TIME OF PAYMENT OF CLAIMS". Since there was no legislation in 1995, or subsequently, making any changes to Subsec. (a)(8), the Revisors editorially corrected their 1995 codification error by reinstating the correct wording of Subsec. (a)(8) for the 2001 revision).

      Annotation to former section 38-167:

      Gardener setting off a single bomb on fourth of July held not to have changed occupation to a more hazardous one. 91 C. 729.

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      Sec. 38a-483a. Exclusionary riders for individual health insurance policies. Regulations. Notwithstanding the provisions of section 38a-476, the Insurance Commissioner may adopt regulations, in accordance with the provisions of chapter 54, to allow exclusionary riders to be issued for individual health insurance policies that are not subject to Section 2701 of the Public Health Service Act, as set forth in the Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191) (HIPAA), as amended from time to time.

      (June 18 Sp. Sess. P.A. 97-8, S. 71, 88.)

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

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      Sec. 38a-483b. Time limits for coverage determinations. Notice requirements. Except as otherwise provided in this title, each insurer, health care center, hospital and medical service corporation or other entity delivering, issuing for delivery, renewing or amending any individual health insurance policy in this state on or after January 1, 2000, providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 shall complete any coverage determination with respect to such policy and notify the insured or the insured's health care provider of its decision not later than forty-five days after a request for such determination is received by the insurer, health care center, hospital and medical service corporation or other entity. In the case of a denial of coverage, such entity shall notify the insured and the insured's health care provider of the reasons for such denial.

      (P.A. 99-284, S. 12.)

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

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      Sec. 38a-483c. Coverage and notice re experimental treatments. Appeals. (a) Each individual health insurance policy delivered, issued for delivery, renewed, amended or continued in this state on or after January 1, 2000, shall define the extent to which it provides coverage for experimental treatments.

      (b) No such health insurance policy may deny a procedure, treatment or the use of any drug as experimental if such procedure, treatment or drug, for the illness or condition being treated, or for the diagnosis for which it is being prescribed, has successfully completed a phase III clinical trial of the federal Food and Drug Administration.

      (c) Any person who has been diagnosed with a condition that creates a life expectancy in that person of less than two years and who has been denied an otherwise covered procedure, treatment or drug on the grounds that it is experimental may request an expedited appeal as provided in section 38a-226c and may appeal a denial thereof to the Insurance Commissioner in accordance with the procedures established in section 38a-478n.

      (d) For the purposes of conducting an appeal pursuant to section 38a-478n on the grounds that an otherwise covered procedure, treatment or drug is experimental, the basis of such an appeal shall be the medical efficacy of such procedure, treatment or drug. The entity conducting the review may consider whether the procedure, treatment or drug (1) has been approved by the National Institute of Health or the American Medical Association, (2) is listed in the United States Pharmacopoeia Drug Information Guide for Health Care Professionals (USP-DI), the American Medical Association Drug Evaluations (AMA-DE), or the American Society of Hospital Pharmacists' American Hospital Formulary Service Drug Information (AHFS-DI), or (3) is currently in a phase III clinical trial of the federal Food and Drug Administration.

      (P.A. 99-284, S. 15, 60.)

      History: P.A. 99-284 effective January 1, 2000.

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

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      Sec. 38a-484. (Formerly Sec. 38-168). Policy provisions not to be less favorable than standard. Validity of policy issued in violation of law. (a) No policy provision which is not subject to section 38a-483 shall make a policy, or any portion thereof, less favorable in any respect to the insured or the beneficiary than the provisions thereof which are subject to sections 38a-481 to 38a-488, inclusive.

      (b) A policy delivered or issued for delivery to any person in this state in violation of said sections shall be held valid but shall be construed as provided in said sections. When any provision in a policy subject to said sections is in conflict with any provision of said sections, the rights, duties and obligations of the insurer, the insured and the beneficiary shall be governed by the provisions of said sections.

      (1949 Rev., S. 6185; 1951, S. 2838d.)

      History: Sec. 38-168 transferred to Sec. 38a-484 in 1991.

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      Sec. 38a-485. (Formerly Sec. 38-169). Copy of application to be part of new policy or to be furnished with renewal. Alteration of application. (a) The insured shall not be bound by any statement made in an application for an individual health insurance policy unless a copy of such application is attached to or endorsed on the policy when issued as a part thereof. If any such policy delivered or issued for delivery to any person in this state is reinstated or renewed, and the insured or the beneficiary or assignee of such policy makes written request to the insurer for a copy of the application, if any, for such reinstatement or renewal, the insurer shall, within fifteen days after the receipt of such request at its home office or any branch office of the insurer, deliver or mail to the person making such request, a copy of such application. If such copy is not so delivered or mailed, the insurer shall be precluded from introducing such application as evidence in any action or proceeding based upon or involving such policy or its reinstatement or renewal.

      (b) No alteration of any written application for any such policy shall be made by any person other than the applicant without his written consent, except that insertions may be made by the insurer, for administrative purposes only, in such manner as to indicate clearly that such insertions are not to be ascribed to the applicant.

      (c) The falsity of any statement in the application for any policy covered by sections 38a-481 to 38a-488, inclusive, may not bar the right to recovery thereunder unless such false statement materially affected either the acceptance of the risk or the hazard assumed by the insurer.

      (1949 Rev., S. 6184; 1951, S. 2839d; P.A. 90-243, S. 75.)

      History: P.A. 90-243 added reference to "an individual health insurance" policy; Sec. 38-169 transferred to Sec. 38a-485 in 1991.

      Annotation to former section 38-169:

      Cited. 214 C. 303, 307, 308.

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      Sec. 38a-486. (Formerly Sec. 38-170). Certain acts not to operate as waiver of rights. The acknowledgment by any insurer of the receipt of notice given under any individual health insurance policy, or the furnishing of forms for filing proofs of loss, or the acceptance of such proofs, or the investigation of any claim thereunder shall not operate as a waiver of any of the rights of the insurer in defense of any claim arising under such policy.

      (1949 Rev., S. 6183; 1951, S. 2840d; P.A. 90-243, S. 76.)

      History: P.A. 90-243 added reference to "an individual health insurance" policy; Sec. 38-170 transferred to Sec. 38a-486 in 1991.

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      Sec. 38a-487. (Formerly Sec. 38-171). Coverage after termination date of policy. If any individual health insurance policy contains a provision establishing, as an age limit or otherwise, a date after which the coverage provided by the policy will not be effective, and if such date falls within a period for which a premium is accepted by the insurer or if the insurer accepts a premium after such date, the coverage provided by the policy will continue in force subject to any right of cancellation until the end of the period for which the premium has been accepted. If the age of the insured has been misstated and if, according to the correct age of the insured, the coverage provided by the policy would not have become effective, or would have ceased prior to the acceptance of such premium or premiums, the liability of the insurer shall be limited to the refund, upon request, of all premiums paid for the period not covered by the policy.

      (1951, S. 2841d; P.A. 90-243, S. 77.)

      History: P.A. 90-243 added reference to "an individual health insurance" policy; Sec. 38-171 transferred to Sec. 38a-487 in 1991.

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      Sec. 38a-488. (Formerly Sec. 38-172). Discrimination. Discrimination between individuals of the same class in the amount of premiums or rates charged for any individual health insurance policy, or in the benefits payable thereon, or in any of the terms or conditions of such policy, or in any other manner, is prohibited.

      (1949 Rev., S. 6188; 1951, S. 2844d; P.A. 90-243, S. 78.)

      History: P.A. 90-243 substituted reference to "individual health insurance" policy for reference to policies under Secs. 38-165 to 38-172; Sec. 38-172 transferred to Sec. 38a-488 in 1991.

      See Sec. 38a-446 re prohibition against discrimination in favor of individuals by life insurance companies.

      See Sec. 38a-447 re prohibition of discrimination against persons on basis of race.

      See Sec. 38a-816 re unfair practices.

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      Sec. 38a-488a. Mandatory coverage for the diagnosis and treatment of mental or nervous conditions. Exceptions. Benefits payable re type of provider or facility. State's claim against proceeds. (a) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state on or after January 1, 2000, shall provide benefits for the diagnosis and treatment of mental or nervous conditions. For the purposes of this section, "mental or nervous conditions" means mental disorders, as defined in the most recent edition of the American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Disorders". "Mental or nervous conditions" does not include (1) mental retardation, (2) learning disorders, (3) motor skills disorders, (4) communication disorders, (5) caffeine-related disorders, (6) relational problems, and (7) additional conditions that may be a focus of clinical attention, that are not otherwise defined as mental disorders in the most recent edition of the American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Disorders".

      (b) No such policy shall establish any terms, conditions or benefits that place a greater financial burden on an insured for access to diagnosis or treatment of mental or nervous conditions than for diagnosis or treatment of medical, surgical or other physical health conditions.

      (c) In the case of benefits payable for the services of a licensed physician, such benefits shall be payable for the same services when such services are lawfully rendered by a psychologist licensed under the provisions of chapter 383 or by such a licensed psychologist in a licensed hospital or clinic.

      (d) In the case of benefits payable for the services of a licensed physician or psychologist, such benefits shall be payable for the same services when such services are rendered by:

      (1) A clinical social worker who is licensed under the provisions of chapter 383b and who has passed the clinical examination of the American Association of State Social Work Boards and has completed at least two thousand hours of post-master's social work experience in a nonprofit agency qualifying as a tax-exempt organization under Section 501(c) of the Internal Revenue Code of 1986 or any subsequent corresponding internal revenue code of the United States, as from time to time amended, in a municipal, state or federal agency or in an institution licensed by the Department of Public Health under section 19a-490;

      (2) A social worker who was certified as an independent social worker under the provisions of chapter 383b prior to October 1, 1990;

      (3) A licensed marital and family therapist who has completed at least two thousand hours of post-master's marriage and family therapy work experience in a nonprofit agency qualifying as a tax-exempt organization under Section 501(c) of the Internal Revenue Code of 1986 or any subsequent corresponding internal revenue code of the United States, as from time to time amended, in a municipal, state or federal agency or in an institution licensed by the Department of Public Health under section 19a-490;

      (4) A marital and family therapist who was certified under the provisions of chapter 383a prior to October 1, 1992;

      (5) A licensed alcohol and drug counselor, as defined in section 20-74s, or a certified alcohol and drug counselor, as defined in section 20-74s; or

      (6) A licensed professional counselor.

      (e) For purposes of this section, the term "covered expenses" means the usual, customary and reasonable charges for treatment deemed necessary under generally accepted medical standards, except that in the case of a managed care plan, as defined in section 38a-478, "covered expenses" means the payments agreed upon in the contract between a managed care organization, as defined in section 38a-478, and a provider, as defined in section 38a-478.

      (f) (1) In the case of benefits payable for the services of a licensed physician, such benefits shall be payable for (A) services rendered in a child guidance clinic or residential treatment facility by a person with a master's degree in social work or by a person with a master's degree in marriage and family therapy under the supervision of a psychiatrist, physician, licensed marital and family therapist, or licensed clinical social worker who is eligible for reimbursement under subdivisions (1) to (4), inclusive, of subsection (d) of this section; (B) services rendered in a residential treatment facility by a licensed or certified alcohol and drug counselor who is eligible for reimbursement under subdivision (5) of subsection (d) of this section; or (C) services rendered in a residential treatment facility by a licensed professional counselor who is eligible for reimbursement under subdivision (6) of subsection (d) of this section.

      (2) In the case of benefits payable for the services of a licensed psychologist under subsection (d) of this section, such benefits shall be payable for (A) services rendered in a child guidance clinic or residential treatment facility by a person with a master's degree in social work or by a person with a master's degree in marriage and family therapy under the supervision of such licensed psychologist, licensed marital and family therapist, or licensed clinical social worker who is eligible for reimbursement under subdivisions (1) to (4), inclusive, of subsection (d) of this section; (B) services rendered in a residential treatment facility by a licensed or certified alcohol and drug counselor who is eligible for reimbursement under subdivision (5) of subsection (d) of this section; or (C) services rendered in a residential treatment facility by a licensed professional counselor who is eligible for reimbursement under subdivision (6) of subsection (d) of this section.

      (g) In the case of benefits payable for the service of a licensed physician practicing as a psychiatrist or a licensed psychologist, under subsection (d) of this section, such benefits shall be payable for outpatient services rendered (1) in a nonprofit community mental health center, as defined by the Department of Mental Health and Addiction Services, in a nonprofit licensed adult psychiatric clinic operated by an accredited hospital or in a residential treatment facility; (2) under the supervision of a licensed physician practicing as a psychiatrist, a licensed psychologist, a licensed marital and family therapist, a licensed clinical social worker, a licensed or certified alcohol and drug counselor or a licensed professional counselor who is eligible for reimbursement under subdivisions (1) to (6), inclusive, of subsection (d) of this section; and (3) within the scope of the license issued to the center or clinic by the Department of Public Health or to the residential treatment facility by the Department of Children and Families.

      (h) Except in the case of emergency services or in the case of services for which an individual has been referred by a physician affiliated with a health care center, nothing in this section shall be construed to require a health care center to provide benefits under this section through facilities that are not affiliated with the health care center.

      (i) In the case of any person admitted to a state institution or facility administered by the Department of Mental Health and Addiction Services, Department of Public Health, Department of Children and Families or the Department of Mental Retardation, the state shall have a lien upon the proceeds of any coverage available to such person or a legally liable relative of such person under the terms of this section, to the extent of the per capita cost of such person's care. Except in the case of emergency services, the provisions of this subsection shall not apply to coverage provided under a managed care plan, as defined in section 38a-478.

      (June 18 Sp. Sess. P.A. 97-8, S. 63, 88; P.A. 99-284, S. 27, 60; P.A. 00-135, S. 10, 21; P.A. 02-24, S. 6.)

      History: June 18 Sp. Sess. P.A. 97-8 effective July 1, 1997; P.A. 99-284 rewrote Subsec. (a) and referenced Subdivs. (1),(2), (4), (11) and (12) of section 38a-469, deleted reference to biologically-based mental or nervous conditions and definition thereof and replaced with provision for coverage of the diagnosis and treatment of mental or nervous conditions, and defined "mental or nervous conditions", added new Subsec. (b) re prohibition on terms, conditions or benefits that place a greater financial burden on insured re mental or nervous conditions than for other conditions, added new Subsec. (c) re benefits payable when rendered by a psychologist, added new Subsec. (d) re benefits payable for enumerated providers, added new Subsec. (e) to define "covered expenses", added new Subsec. (f) re benefits payable for services rendered in certain facilities, added new Subsec. (g) re certain outpatient benefits, added new Subsec. (h) re benefits provided by a health care center, and added new Subsec. (i) re state liens against certain coverage proceeds, effective January 1, 2000; P.A. 00-135 reorganized section and added provisions re licensed professional counselors, effective May 26, 2000; P.A. 02-24 deleted "the" re "post-master's social work experience" in Subsec. (d)(1) and (3).

      See Sec. 38a-514 for similar provisions re group policies.

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      Sec. 38a-489. (Formerly Sec. 38-174e). Continuation of coverage of mentally or physically handicapped children. (a) Every individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469, delivered or issued for delivery in this state more than one hundred twenty days after July 1, 1971, which provides that coverage of a dependent child shall terminate upon attainment of the limiting age for dependent children specified in the policy shall also provide in substance that attainment of the limiting age shall not operate to terminate the coverage of the child if at such date the child is and continues thereafter to be both (1) incapable of self-sustaining employment by reason of mental or physical handicap, as certified by the child's physician on a form provided by the insurer, hospital or medical service corporation or health care center, and (2) chiefly dependent upon the policyholder or subscriber for support and maintenance.

      (b) Proof of the incapacity and dependency shall be furnished to the insurer, hospital or medical service plan corporation or health care center by the policyholder or subscriber within thirty-one days of the child's attainment of the limiting age. The insurer, corporation or health care center may at any time require proof of the child's continuing incapacity and dependency. After a period of two years has elapsed following the child's attainment of the limiting age the insurer, corporation or health care center may require periodic proof of the child's continuing incapacity and dependency but in no case more frequently than once every year.

      (1971, P.A. 408, S. 1, 2; P.A. 87-207, S. 1; P.A. 90-243, S. 79.)

      History: P.A. 87-207 amended Subsecs. (a) and (b) to provide that for individual and group policies the continuation rights for children are applicable if the child is incapable of employment by reason of mental or physical handicap which has been certified by the child's physician; P.A. 90-243 substituted reference to "health insurance policy" for reference to hospital or medical expense policies and contracts, divided former Subsec. (a) into Subsecs. (a) and (b), added a reference to "health care center" and deleted former Subsec. (b) re group policies; Sec. 38-174e transferred to Sec. 38a-489 in 1991.

      See Sec. 38a-515 for similar provisions re group policies.

      See Sec. 38a-538 re conversion and extension rights of group members and re liability of group employers.

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      Sec. 38a-490. (Formerly Sec. 38-174g). Coverage for newborn infants in health insurance policies. Notice. Application. (a) Every individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469 for a family member of the insured or subscriber shall, as to such family members' coverage, also provide that the health insurance benefits applicable for children shall be payable with respect to a newly born child of the insured or subscriber from the moment of birth.

      (b) Coverage for such newly born child shall consist of coverage for injury and sickness including necessary care and treatment of medically diagnosed congenital defects and birth abnormalities within the limits of the policy.

      (c) If payment of a specific premium or subscription fee is required to provide coverage for a child, the policy or contract may require that notification of birth of such newly born child and payment of the required premium or fees shall be furnished to the insurer, hospital or medical service corporation or health care center within thirty-one days after the date of birth in order to continue coverage beyond such thirty-one-day period, provided failure to furnish such notice or pay such premium or fees shall not prejudice any claim originating within such thirty-one-day period.

      (d) The provisions of this section shall apply with respect to health insurance policies delivered or issued for delivery in this state on or after October 1, 1974, and to any health insurance policies which are thereafter amended to substantially alter or change benefits or coverages, and to any individual health insurance policies renewable at the option of such insurance company, hospital or medical service corporation or health care center which are thereafter renewed.

      (P.A. 74-6, S. 1-4; P.A. 90-243, S. 80.)

      History: P.A. 90-243 substituted references to "health insurance policies" for references to hospital and medical expense policies and contracts, specified applicability to individual policies only, and applied provisions to "health care centers"; Sec. 38-174g transferred to Sec. 38a-490 in 1991.

      See Sec. 38a-516 for similar provisions re group policies.

      See Sec. 38a-538 re conversion and extension rights of group members and re liability of group employers.

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      Sec. 38a-490a. Coverage for birth-to-three program. Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery or renewed in this state on or after July 1, 1996, shall provide coverage for medically necessary early intervention services provided as part of an individualized family service plan pursuant to section 17a-248e. Such policy shall provide (1) coverage for such services provided by qualified personnel, as defined in section 17a-248, for a child from birth until the child's third birthday, and (2) a maximum benefit of three thousand two hundred dollars per child per year and an aggregate benefit of nine thousand six hundred dollars per child over the total three-year period. No payment made under this section shall be applied by the insurer, health care center or plan administrator against any maximum lifetime or annual limits specified in the policy or health benefits plan.

      (P.A. 96-185, S. 6, 16; June 30 Sp. Sess. P.A. 03-3, S. 7.)

      History: P.A. 96-185 effective July 1, 1996; June 30 Sp. Sess. P.A. 03-3 deleted provision re coverage for at least five thousand dollars annually, added Subdivs. (1) and (2) re coverage and benefits to be provided by policy and made technical changes, effective August 20, 2003.

      See Sec. 38a-516a for similar provisions re group policies.

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      Sec. 38a-490b. Coverage for hearing aids for children twelve and under. Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state on or after October 1, 2001, shall provide coverage for hearing aids for children twelve years of age or younger. Such hearing aids shall be considered durable medical equipment under the policy and the policy may limit the hearing aid benefit to one thousand dollars within a twenty-four-month period.

      (P.A. 01-171, S. 15.)

      See Sec. 38a-516b for similar provisions re group policies.

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      Sec. 38a-490c. Coverage for craniofacial disorders. Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state on or after October 1, 2003, shall provide coverage for medically necessary orthodontic processes and appliances for the treatment of craniofacial disorders for individuals eighteen years of age or younger if such processes and appliances are prescribed by a craniofacial team recognized by the American Cleft Palate-Craniofacial Association, except that no coverage shall be required for cosmetic surgery.

      (P.A. 03-37, S. 1.)

      See Sec. 38a-516c for similar provisions re group policies.

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      Sec. 38a-491. (Formerly Sec. 38-174h). Coverage for services performed by dentists in certain instances. Whenever the term "physician" or "doctor" is used in any individual health insurance policy delivered, issued for delivery or renewed in this state on or after October 1, 1975, it shall be deemed to include persons licensed, under the provisions of chapter 379, to engage in the practice of dentistry or dental medicine, when benefits under such policy or contract for care, treatment or services rendered or procedures performed by such person would be payable if rendered or performed by a person licensed under chapter 370.

      (P.A. 75-449; P.A. 90-243, S. 81.)

      History: P.A. 90-243 substituted reference to "health insurance policy" for reference to hospital and medical expense policies and contracts and specified applicability to individual policies only; Sec. 38-174h transferred to Sec. 38a-491 in 1991.

      See Sec. 38a-517 for similar provisions re group policies.

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      Sec. 38a-491a. Coverage for in-patient, outpatient or one-day dental services in certain instances. (a) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed or continued in this state on or after January 1, 2000, shall provide coverage for general anesthesia, nursing and related hospital services provided in conjunction with in-patient, outpatient or one-day dental services if the following conditions are met:

      (1) The anesthesia, nursing and related hospital services are deemed medically necessary by the treating dentist or oral surgeon and the patient's primary care physician in accordance with the health insurance policy's requirements for prior authorization of services; and

      (2) The patient is either (A) determined by a licensed dentist, in conjunction with a licensed physician who specializes in primary care, to have a dental condition of significant dental complexity that it requires certain dental procedures to be performed in a hospital, or (B) a person who has a developmental disability, as determined by a licensed physician who specializes in primary care, that places the person at serious risk.

      (b) The expense of such anesthesia, nursing and related hospital services shall be deemed a medical expense under such health insurance policy and shall not be subject to any limits on dental benefits under such policy.

      (P.A. 99-284, S. 40, 60; P.A. 00-135, S. 13, 21; P.A. 03-58, S. 1.)

      History: P.A. 99-284 effective January 1, 2000; P.A. 00-135 added outpatient or one-day dental services, effective May 26, 2000; P.A. 03-58 divided existing provisions into Subsecs. (a) and (b) and deleted "a child under the age of four who is" in Subsec. (a)(2)(A).

      See Sec. 38a-517a for similar provisions re group policies.

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      Sec. 38a-491b. Assignment of benefits to a dentist or oral surgeon. No insurer, health care center, hospital and medical service corporation or other entity delivering, issuing for delivery, renewing, continuing or amending any individual health insurance policy in this state on or after July 1, 2000, providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469, and no dental services plan offering or administering dental services may refuse to accept or make reimbursement pursuant to an assignment of benefits made to a dentist or oral surgeon by an insured, subscriber or enrollee, provided (1) the dentist or oral surgeon charges the insured, subscriber or enrollee no more for services than the dentist or surgeon charges uninsured patients for the same services, and (2) the dentist or oral surgeon allows the insurer, health care center, corporation or entity to review the records related to the insured, subscriber or enrollee during regular business hours. The insurer, health care center, corporation or entity shall give the dentist or oral surgeon at least forty-eight hours' notice prior to such review. As used in this section, "assignment of benefits" means the transfer of dental care coverage reimbursement benefits or other rights under an insurance policy, subscription contract or dental services plan by an insured, subscriber or enrollee to a dentist or oral surgeon.

      (P.A. 00-33, S. 1, 3.)

      History: P.A. 00-33 effective July 1, 2000.

      See Sec. 38a-517b for similar provisions re group policies.

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      Sec. 38a-492. (Formerly Sec. 38-174i). Coverage for accidental ingestion or consumption of controlled drugs. Benefits prescribed. No individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10) and (11) of section 38a-469 shall be delivered, issued for delivery or renewed in this state, or amended to substantially alter or change benefits or coverage, on or after July 1, 1975, unless persons covered under such policy will be eligible for benefits for expenses of emergency medical care arising from accidental ingestion or consumption of a controlled drug, as defined by subdivision (8) of section 21a-240, which are at least equal to the following minimum requirements: (1) In the case of benefits based upon confinement as an inpatient in a hospital, whether or not operated by the state, the period of confinement for which benefits shall be payable shall be at least thirty days in any calendar year. (2) For covered expenses incurred by the insured while other than an inpatient in a hospital, benefits shall be available for such expenses during any calendar year up to a maximum of five hundred dollars. For purposes of this section, the term "covered expenses" means the reasonable charges for treatment deemed necessary under generally accepted medical standards.

      (P.A. 75-512, S. 1, 2; P.A. 85-613, S. 73, 154; P.A. 90-243, S. 82.)

      History: P.A. 85-613 made technical change; P.A. 90-243 substituted reference to "health insurance policy" for reference to hospital and medical expense policies or contracts, specified applicability to individual policies only, and replaced alphabetic Subdiv. indicators with numeric ones; Sec. 38-174i transferred to Sec. 38a-492 in 1991; (Revisor's note: In 2001, a reference to "subsection (a) of" Sec. 38a-469 was deleted editorially by the Revisors for accuracy).

      See Sec. 38a-518 for similar provisions re group policies.

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      Sec. 38a-492a. Mandatory coverage for hypodermic needles and syringes. Every individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469, delivered, issued for delivery or renewed in this state on or after July 1, 1992, shall provide coverage for hypodermic needles or syringes prescribed by a prescribing practitioner, as defined in subdivision (22) of section 20-571, for the purpose of administering medications for medical conditions, provided such medications are covered under the policy. Such benefits shall be subject to any policy provisions that apply to other services covered by such policy.

      (P.A. 92-185, S. 4, 6; P.A. 95-264, S. 62.)

      History: P.A. 95-264 substituted "prescribing practitioner" for "licensed practitioner" (Revisor's note: The reference to "prescribing practitioner, as defined in subdivision (21) of ..." was changed editorially by the Revisors to "prescribing practitioner, as defined in subdivision (22) of ...").

      See Sec. 38a-518a for similar provisions re group policies.

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      Sec. 38a-492b. Coverage for off-label drug prescriptions. (a) Each individual health insurance policy delivered, issued for delivery or renewed in this state on or after October 1, 1994, which provides coverage for prescribed drugs approved by the federal Food and Drug Administration for treatment of certain types of cancer shall not exclude coverage of any such drug on the basis that such drug has been prescribed for the treatment of a type of cancer for which the drug has not been approved by the federal Food and Drug Administration, provided the drug is recognized for treatment of the specific type of cancer for which the drug has been prescribed in one of the following established reference compendia: (1) The U.S. Pharmacopoeia Drug Information Guide for the Health Care Professional (USP DI); (2) The American Medical Association's Drug Evaluations (AMA DE); or (3) The American Society of Hospital Pharmacists' American Hospital Formulary Service Drug Information (AHFS-DI).

      (b) Nothing in subsection (a) of this section shall be construed to require coverage for any experimental or investigational drugs or any drug which the federal Food and Drug Administration has determined to be contraindicated for treatment of the specific type of cancer for which the drug has been prescribed.

      (c) Nothing in this section shall be construed to create, impair, limit or modify authority to provide reimbursement for drugs used in the treatment of any other disease or condition.

      (P.A. 94-49, S. 2.)

      See Sec. 38a-518b for similar provisions re group policies.

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      Sec. 38a-492c. Coverage for low protein modified food products, amino acid modified preparations and specialized formulas. (a) For purposes of this section:

      (1) "Inherited metabolic disease" includes (A) a disease for which newborn screening is required under section 19a-55; and (B) cystic fibrosis.

      (2) "Low protein modified food product" means a product formulated to have less than one gram of protein per serving and intended for the dietary treatment of an inherited metabolic disease under the direction of a physician.

      (3) "Amino acid modified preparation" means a product intended for the dietary treatment of an inherited metabolic disease under the direction of a physician.

      (4) "Specialized formula" means a nutritional formula for children up to age eight that is exempt from the general requirements for nutritional labeling under the statutory and regulatory guidelines of the federal Food and Drug Administration and is intended for use solely under medical supervision in the dietary management of specific diseases.

      (b) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (11) and (12) of section 38a-469 delivered, issued for delivery or renewed in this state on or after October 1, 1997, shall provide coverage for amino acid modified preparations and low protein modified food products for the treatment of inherited metabolic diseases if the amino acid modified preparations or low protein modified food products are prescribed for the therapeutic treatment of inherited metabolic diseases and are administered under the direction of a physician.

      (c) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (11) and (12) of section 38a-469 delivered, issued for delivery or renewed in this state on or after October 1, 2001, shall provide coverage for specialized formulas when such specialized formulas are medically necessary for the treatment of a disease or condition and are administered under the direction of a physician.

      (d) Such policy shall provide coverage for such preparations, food products and formulas on the same basis as outpatient prescription drugs.

      (P.A. 97-167, S. 1; P.A. 01-101, S. 1; P.A. 04-173, S. 1.)

      History: P.A. 01-101 defined, in new Subsec. (a)(4), and added coverage, in new Subsec. (c), for specialized formula; P.A. 04-173 amended Subsec. (a)(1) and (4) to redefine "inherited metabolic disease" to include cystic fibrosis and redefine "specialized formula" to include formula for children up to age eight, instead of age three, and added Subsec. (d) to require coverage on the same basis as for outpatient prescription drugs.

      See Sec. 38a-518c for similar provisions re group policies.

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      Sec. 38a-492d. Mandatory coverage for diabetes testing and treatment. (a) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery or renewed in this state on or after October 1, 1997, shall provide coverage for laboratory and diagnostic tests for all types of diabetes.

      (b) Notwithstanding the provisions of section 38a-492a, each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery or renewed in this state on or after October 1, 1997, shall provide medically necessary coverage for the treatment of insulin-dependent diabetes, insulin-using diabetes, gestational diabetes and non-insulin-using diabetes. Such coverage shall include medically necessary equipment, in accordance with the insured person's treatment plan, drugs and supplies prescribed by a prescribing practitioner, as defined in section 20-571.

      (P.A. 97-268, S. 4.)

      See Sec. 38a-518d for similar provisions re group policies.

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      Sec. 38a-492e. Mandatory coverage for diabetes outpatient self-management training. (a) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed or continued in this state on or after January 1, 2000, shall provide coverage for outpatient self-management training for the treatment of insulin-dependent diabetes, insulin-using diabetes, gestational diabetes and non-insulin-using diabetes if the training is prescribed by a licensed health care professional who has appropriate state licensing authority to prescribe such training. As used in this section, "outpatient self-management training" includes, but is not limited to, education and medical nutrition therapy. Diabetes self-management training shall be provided by a certified, registered or licensed health care professional trained in the care and management of diabetes and authorized to provide such care within the scope of the professional's practice.

      (b) Benefits shall cover: (1) Initial training visits provided to an individual after the individual is initially diagnosed with diabetes that is medically necessary for the care and management of diabetes, including, but not limited to, counseling in nutrition and the proper use of equipment and supplies for the treatment of diabetes, totaling a maximum of ten hours; (2) training and education that is medically necessary as a result of a subsequent diagnosis by a physician of a significant change in the individual's symptoms or condition which requires modification of the individual's program of self-management of diabetes, totaling a maximum of four hours; and (3) training and education that is medically necessary because of the development of new techniques and treatment for diabetes totaling a maximum of four hours.

      (c) Benefits provided pursuant to this section shall be subject to the same terms and conditions applicable to all other benefits under such policies.

      (P.A. 99-284, S. 43, 60.)

      History: P.A. 99-284 effective January 1, 2000.

      See Sec. 38a-518e for similar provisions re group policies.

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      Sec. 38a-492f. Mandatory coverage for certain prescription drugs removed from formulary. Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed or continued in this state on or after January 1, 2000, that provides coverage for outpatient prescription drugs shall not deny coverage for an insured for any drug that the insurer removes from its list of covered drugs, or otherwise ceases to provide coverage for, if (1) the insured was using the drug for the treatment of a chronic illness prior to the removal or cessation of coverage, (2) the insured was covered under the policy for the drug prior to the removal or cessation of coverage, and (3) the insured's attending health care provider states in writing, after the removal or cessation of coverage, that the drug is medically necessary and lists the reasons why the drug is more medically beneficial than the drugs on the list of covered drugs. Such benefits shall be subject to the same terms and conditions applicable to all other benefits under such policies.

      (P.A. 99-284, S. 37, 60.)

      History: P.A. 99-284 effective January 1, 2000.

      See Sec. 38a-518f for similar provisions re group policies.

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      Sec. 38a-492g. Mandatory coverage for prostate cancer screening. Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed or continued in this state on or after January 1, 2000, shall provide coverage for laboratory and diagnostic tests, including, but not limited to, prostate specific antigen (PSA) tests, to screen for prostate cancer for men who are symptomatic, whose biological father or brother has been diagnosed with prostate cancer, and for all men fifty years of age or older.

      (P.A. 99-284, S. 45, 60.)

      History: P.A. 99-284 effective January 1, 2000.

      See Sec. 38a-518g for similar provisions re group policies.

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      Sec. 38a-492h. Mandatory coverage for certain Lyme disease treatments. Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed or continued in this state on or after January 1, 2000, shall provide coverage for Lyme disease treatment including not less than thirty days of intravenous antibiotic therapy, sixty days of oral antibiotic therapy, or both, and shall provide further treatment if recommended by a board certified rheumatologist, infectious disease specialist or neurologist licensed in accordance with chapter 370 or who is licensed in another state or jurisdiction whose requirements for practicing in such capacity are substantially similar to or higher than those of this state.

      (P.A. 99-284, S. 47, 60; June Sp. Sess. P.A. 99-2, S. 2, 72.)

      History: P.A. 99-284 effective January 1, 2000; June Sp. Sess. P.A. 99-2 added specialists "licensed in another state or jurisdiction whose requirements for practicing in such capacity are substantially similar to or higher than those of this state", effective January 1, 2000.

      See Sec. 38a-518h for similar provisions re group policies.

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      Sec. 38a-492i. Mandatory coverage for pain management. Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (10), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state on or after January 1, 2001, shall provide access to a pain management specialist and coverage for pain treatment ordered by such specialist which may include all means medically necessary to make a diagnosis and develop a treatment plan including the use of necessary medications and procedures. As used in this section, "pain" means a sensation in which a person experiences severe discomfort, distress or suffering due to provocation of sensory nerves, and "pain management specialist" means a physician who is credentialed by the American Academy of Pain Management or who is a board-certified anesthesiologist, neurologist, oncologist or radiation oncologist with additional training in pain management.

      (P.A. 00-216, S. 18, 28.)

      History: P.A. 00-216 effective January 1, 2001.

      See Sec. 38a-518i re group health insurance coverage for pain management.

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      Sec. 38a-492j. Mandatory coverage for ostomy-related supplies. Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed or continued in this state on or after October 1, 2000, that provides coverage for ostomy surgery shall include coverage, up to one thousand dollars annually, for medically necessary appliances and supplies relating to an ostomy including, but not limited to, collection devices, irrigation equipment and supplies, skin barriers and skin protectors. As used in this section, "ostomy" includes colostomy, ileostomy and urostomy. Payments under this section shall not be applied to any policy maximums for durable medical equipment. Nothing in this section shall be deemed to decrease policy benefits in excess of the limits in this section.

      (P.A. 00-63, S. 1.)

      See Sec. 38a-518j for similar provisions re group policies.

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      Sec. 38a-492k. Mandatory coverage for colorectal cancer screening. Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state on or after October 1, 2001, shall provide coverage for colorectal cancer screening, including, but not limited to, (1) an annual fecal occult blood test, and (2) colonoscopy, flexible sigmoidoscopy or radiologic imaging, in accordance with the recommendations established by the American College of Gastroenterology, after consultation with the American Cancer Society, based on the ages, family histories and frequencies provided in the recommendations. Benefits under this section shall be subject to the same terms and conditions applicable to all other benefits under such policies.

      (P.A. 01-171, S. 20.)

      See Sec. 38a-518k for similar provisions re group policies.

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      Sec. 38a-493. (Formerly Sec. 38-174k). Mandatory coverage for home health care. Deductibles. Exception from deductible limits for medical savings accounts, Archer MSAs and health savings accounts. (a) Every individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469 delivered, issued for delivery or renewed in this state on or after October 1, 1975, shall provide coverage providing reimbursement for home health care to residents in this state.

      (b) For the purposes of this section, "hospital" means an institution which is primarily engaged in providing, by or under the supervision of physicians, to inpatients (1) diagnostic, surgical and therapeutic services for medical diagnosis, treatment and care of injured, disabled or sick persons, or (2) medical rehabilitation services for the rehabilitation of injured, disabled or sick persons, provided "hospital" shall not include a residential care home, nursing home, rest home or alcohol or drug treatment facility, as defined in section 19a-490. For the purposes of this section and section 38a-494, "home health care" means the continued care and treatment of a covered person who is under the care of a physician but only if (A) continued hospitalization would otherwise have been required if home health care was not provided, except in the case of a covered person diagnosed by a physician as terminally ill with a prognosis of six months or less to live, and (B) the plan covering the home health care is established and approved in writing by such physician within seven days following termination of a hospital confinement as a resident inpatient for the same or a related condition for which the covered person was hospitalized, except that in the case of a covered person diagnosed by a physician as terminally ill with a prognosis of six months or less to live, such plan may be so established and approved at any time irrespective of whether such covered person was so confined or, if such covered person was so confined, irrespective of such seven-day period, and (C) such home health care is commenced within seven days following discharge, except in the case of a covered person diagnosed by a physician as terminally ill with a prognosis of six months or less to live.

      (c) Home health care shall be provided by a home health agency. The term "home health agency" means an agency or organization which meets each of the following requirements: (1) It is primarily engaged in and is federally certified as a home health agency and duly licensed, if such licensing is required, by the appropriate licensing authority, to provide nursing and other therapeutic services, (2) its policies are established by a professional group associated with such agency or organization, including at least one physician and at least one registered nurse, to govern the services provided, (3) it provides for full-time supervision of such services by a physician or by a registered nurse, (4) it maintains a complete medical record on each patient, and (5) it has an administrator.

      (d) Home health care shall consist of, but shall not be limited to, the following: (1) Part-time or intermittent nursing care by a registered nurse or by a licensed practical nurse under the supervision of a registered nurse, if the services of a registered nurse are not available; (2) part-time or intermittent home health aide services, consisting primarily of patient care of a medical or therapeutic nature by other than a registered or licensed practical nurse; (3) physical, occupational or speech therapy; (4) medical supplies, drugs and medicines prescribed by a physician, advanced practice registered nurse or physician assistant and laboratory services to the extent such charges would have been covered under the policy or contract if the covered person had remained or had been confined in the hospital; (5) medical social services, as hereinafter defined, provided to or for the benefit of a covered person diagnosed by a physician as terminally ill with a prognosis of six months or less to live. Medical social services are defined to mean services rendered, under the direction of a physician by a qualified social worker holding a master's degree from an accredited school of social work, including but not limited to (A) assessment of the social, psychological and family problems related to or arising out of such covered person's illness and treatment; (B) appropriate action and utilization of community resources to assist in resolving such problems; (C) participation in the development of the overall plan of treatment for such covered person.

      (e) The policy may contain a limitation on the number of home health care visits for which benefits are payable, but the number of such visits shall not be less than eighty in any calendar year or in any continuous period of twelve months for each person covered under a policy or contract, except in the case of a covered person diagnosed by a physician as terminally ill with a prognosis of six months or less to live, the yearly benefit for medical social services shall not exceed two hundred dollars. Each visit by a representative of a home health agency shall be considered as one home health care visit; four hours of home health aide service shall be considered as one home health care visit.

      (f) Home health care benefits may be subject to an annual deductible of not more than fifty dollars for each person covered under a policy and may be subject to a coinsurance provision which provides for coverage of not less than seventy-five per cent of the reasonable charges for such services. Such policy may also contain reasonable limitations and exclusions applicable to home health care coverage. A "high deductible health plan", as defined in Section 220(c)(2) or Section 223(c)(2) of the Internal Revenue Code of 1986, or any subsequent corresponding internal revenue code of the United States, as from time to time amended, used to establish a "medical savings account" or "Archer MSA" pursuant to Section 220 of said Internal Revenue Code or a "health savings account" pursuant to Section 223 of said Internal Revenue Code shall not be subject to the deductible limits set forth in this subsection.

      (g) No policy, except any major medical expense policy as described in subsection (j), shall be required to provide home health care coverage to persons eligible for Medicare.

      (h) No insurer, hospital service corporation or health care center shall be required to provide benefits beyond the maximum amount limits contained in its policy.

      (i) If a person is eligible for home health care coverage under more than one policy, the home health care benefits shall only be provided by that policy which would have provided the greatest benefits for hospitalization if the person had remained or had been hospitalized.

      (j) Every individual major medical expense policy delivered, issued for delivery or renewed in this state on or after October 1, 1989, shall provide coverage in accordance with the provisions of this section for home health care to residents in this state whose benefits are no longer provided under Medicare or any applicable individual health insurance policy.

      (P.A. 75-623, S. 1; P.A. 78-76, S. 1-3, 5; P.A. 84-375, S. 1, 3; P.A. 89-284; P.A. 90-243, S. 83; P.A. 96-19, S. 6; P.A. 97-112, S. 2; P.A. 03-78, S. 1; P.A. 04-174, S. 6.)

      History: P.A. 78-76 specified applicability or inapplicability of provisions with respect to persons diagnosed as terminally ill with six months or less to live in Subsecs. (b), (d) and (e) and added "or had been" in Subsec. (i) preceding "hospitalized"; P.A. 84-375 amended Subsec. (g) to exclude major medical expense policies, as described in Subsec. (j), from the exemption in the subsection and added Subsec. (j), requiring that each major medical policy delivered, issued or renewed on or after October 1, 1984, provide coverage for home health care to residents who have exhausted their other policy or contract benefits; P.A. 89-284 amended Subsec. (b) to include a definition of "hospital" and amended Subsec. (j) to clarify that home health care shall be provided in accordance with this section under the major medical policies of insureds whose benefits are no longer provided under Medicare; P.A. 90-243 substituted references to "health insurance policies" for references to hospital and medical expense policies or contracts, added reference to health care centers and specified applicability solely to individual policies (Revisor's note: The reference to "or contract" at the end of Subsec. (h) was deleted editorially by the Revisors for conformity with the changes made by P.A. 90-243); Sec. 38-174k transferred to Sec. 38a-493 in 1991; P.A. 96-19 expanded reference in Subsec. (d) to prescriptions by physicians to include advanced practice registered nurses and physician assistants; P.A. 97-112 replaced "home for the aged" with "residential care home"; P.A. 03-78 amended Subsec. (f) to provide that a high deductible health plan shall not be subject to the deductible limits set forth in said Subsec., effective July 1, 2003; P.A. 04-174 amended Subsec. (f) to add references to "Archer MSA", "health savings account" and Section 223 of the Internal Revenue Code re "high deductible health plans", effective June 1, 2004.

      See Sec. 38a-520 for similar provisions re group policies.

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      Sec. 38a-494. (Formerly Sec. 38-174l). Home health care by recognized nonmedical systems. Notwithstanding the provisions of section 38a-493, no insurer, health care center or issuer of any service plan contract for hospital or medical expense delivered, issued for delivery or renewed in this state shall be prohibited from providing, at its own discretion, coverage for home health care to persons employing a recognized nonmedical system of health care and treatment.

      (P.A. 75-623, S. 2; P.A. 90-243, S. 84.)

      History: P.A. 90-243 added reference to health care centers; Sec. 38-174l transferred to Sec. 38a-494 in 1991.

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      Sec. 38a-495. (Formerly Sec. 38-174m). Medicare supplement policies. Coverage of home health aid services and mammography. Prescription drug riders. (a) As used in this section, "Medicare" means the Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965, as amended (Title I, Part I of P.L. 89-97); "Medicare supplement policy" means any individual health insurance policy delivered or issued for delivery to any resident of the state who is eligible for Medicare, except any long-term care policy as defined in section 38a-501.

      (b) No insurance company, fraternal benefit society, hospital service corporation, medical service corporation or health care center may deliver or issue for delivery any Medicare supplement policy which has an anticipated loss ratio of less than sixty-five per cent for any individual Medicare supplement policy defined in Section 1882(g) of Title XVIII of the Social Security Act, 42 USC 1395ss(g), as amended. No such company, society or corporation may deliver or issue for delivery any Medicare supplement policy without providing, at the time of solicitation or application for the purchase or sale of such coverage, full and fair disclosure of any coverage supplementing or duplicating Medicare benefits.

      (c) Each Medicare supplement policy shall provide coverage for home health aide services for each individual covered under the policy when such services are not paid for by Medicare, provided (1) such services are provided by a certified home health aide employed by a home health care agency licensed pursuant to sections 19a-490 to 19a-503, inclusive, and (2) the individual's physician has certified, in writing, that such services are medically necessary. The policy shall not be required to provide benefits in excess of five hundred dollars per year for such services. No deductible or coinsurance provisions may be applicable to such benefits. If two or more Medicare supplement policies are issued to the same individual by the same insurer, such coverage for home health aide services shall be included in only one such policy. Notwithstanding the provisions of subsection (g) of this section, the provisions of this subsection shall apply with respect to any Medicare supplement policy delivered, issued for delivery, continued or renewed in this state on or after October 1, 1986.

      (d) Whenever a Medicare supplement policy provides coverage for the cost of prescription drugs prescribed after the hospitalization of the insured, outpatient surgical procedures performed on the insured in any licensed hospital shall constitute "hospitalization" for purposes of such prescription drug coverage in such policy.

      (e) Notwithstanding the provisions of subsection (g) of this section, each Medicare supplement policy delivered, issued for delivery, continued or renewed in this state on or after October 1, 1988, shall provide benefits, to any woman covered under the policy, for mammographic examinations every year, or more frequently if recommended by the woman's physician, when such examinations are not paid for by Medicare.

      (f) The Insurance Commissioner shall adopt such regulations as he deems necessary in accordance with chapter 54 to carry out the purposes of this section.

      (g) The provisions of this section shall apply with respect to any Medicare supplement policy delivered, issued for delivery, continued or renewed in this state on or after October 1, 1987, and prior to the effective date of any regulations adopted pursuant to section 38a-495a.

      (P.A. 79-289, S. 1, 2; P.A. 81-97; P.A. 86-49, S. 1, 3; 86-152; P.A. 87-181; 87-502; P.A. 88-124, S. 2; P.A. 90-243, S. 85; P.A. 92-111, S. 2, 4.)

      History: P.A. 81-97 amended Subsec. (b), providing that a loss ratio of seventy-five per cent be required for a group medicare supplement policy defined in the federal act; P.A. 86-49 excluded long-term care policies from the definition of "Medicare supplement policy"; P.A. 86-152 inserted new Subsec. (c) requiring that Medicare supplement policies provide coverage for home health aide services, relettering prior Subsecs. as necessary; P.A. 87-181 amended Subsec. (c) to make its provisions applicable to any Medicare supplement policy delivered, issued for delivery, continued or renewed on or after October 1, 1986; P.A. 87-502 inserted new Subsec. (d) defining what constitutes "hospitalization" for purposes of prescription drug coverage, relettering prior Subsecs. as necessary; P.A. 88-124 inserted new Subsec. (e) requiring that Medicare supplement policies provide coverage for mammography, relettering prior Subsecs. as necessary; P.A. 90-243 added references to health care centers, deleted provisions concerning group policies and substituted reference to health insurance policies for reference to accident and sickness policies; Sec. 38-174m transferred to Sec. 38a-495 in 1991; P.A. 92-111 amended Subsec. (g) to make the provisions of this section applicable to Medicare supplement policy regulations adopted pursuant to Sec. 38a-495a.

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

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

      See Sec. 38a-495a re Medicare supplement policies and certificates.

      See Sec. 38a-522 re group Medicare supplement policies and certificates.

      See Secs. 38a-595 to 38a-626, inclusive, 38a-631 to 38a-640, inclusive, and 38a-800 re fraternal benefit societies.

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      Sec. 38a-495a. Medicare supplement policies and certificates. Minimum required policy benefits and standards. Regulations. (a) As used in this section:

      (1) "Applicant" means (A) in the case of an individual Medicare supplement policy, a person who seeks to contract for insurance benefits or (B) in the case of a group Medicare supplement policy, a proposed certificate holder.

      (2) "Certificate" means any certificate delivered or issued for delivery in this state under a group Medicare supplement policy.

      (3) "Certificate form" means a form on which the certificate is delivered or issued for delivery by an insurer.

      (4) "Commissioner" means the Insurance Commissioner.

      (5) "Issuer" means any insurance company, fraternal benefit society, hospital or medical service corporation, health care center or any other entity which delivers or issues for delivery, in this state, any Medicare supplement policies or certificates.

      (6) "Medicare" means the Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965, as then constituted or later amended.

      (7) "Medicare supplement policy" means (A) a group or individual policy of accident and sickness insurance or (B) a subscriber contract of hospital and medical service corporations or health care centers, other than a policy issued pursuant to a contract under Section 1876 of the federal Social Security Act (42 USC Section 1395 et seq.), or (C) an issued policy under a demonstration project specified in 42 USC Section 1395ss(g)(1), which is advertised, marketed or designed primarily as a supplement to reimbursements under Medicare for the hospital, medical or surgical expenses of persons eligible for Medicare.

      (8) "Policy form" means the form on which the policy is delivered or issued for delivery by the issuer.

      (b) Except as otherwise specifically excluded, this section shall apply to all Medicare supplement policies and certificates delivered or issued for delivery in this state on or after July 30, 1992.

      (c) This section shall not apply to a policy of one or more employers or labor organizations, or of the trustees of a fund established by one or more employers or labor organizations, or combination thereof, for employees or former employees or a combination thereof, or for members or former members, or a combination thereof, of the labor organizations.

      (d) Except as otherwise specifically provided in subdivision (4) of subsection (l) of this section, the provisions of this section shall not apply to insurance policies or health care benefit plans, including group conversion policies, provided to Medicare eligible persons which policies are not marketed or held to be Medicare supplement policies or benefit plans.

      (e) No Medicare supplement policy or certificate in force in this state shall contain benefits that duplicate benefits provided by Medicare.

      (f) Notwithstanding any other provision of law to the contrary, a Medicare supplement policy or certificate shall not exclude or limit benefits for losses incurred more than six months from the effective date of coverage because it involved a preexisting condition. The policy or certificate shall not define a preexisting condition more restrictively than a condition for which medical advice was given or treatment was recommended by or received from a physician within six months before the effective date of coverage.

      (g) The commissioner shall adopt regulations in accordance with chapter 54 to establish specific standards for policy provisions of Medicare supplement policies and certificates. No requirements of this title relating to minimum required policy benefits, other than the minimum standards contained in this section, shall apply to Medicare supplement policies and certificates. The standards may include but need not be limited to the following: (1) Terms of renewability; (2) initial and subsequent conditions of eligibility; (3) nonduplication of coverage; (4) probationary periods; (5) benefit limitations, exceptions and reductions; (6) elimination periods; (7) requirements for replacement; (8) recurrent conditions; and (9) definitions of terms.

      (h) The commissioner shall adopt regulations, in accordance with chapter 54, to establish minimum standards for benefits, claim payments, marketing practices, compensation arrangements and reporting practices for Medicare supplement policies and certificates.

      (i) The commissioner may adopt such regulations, in accordance with chapter 54, as are necessary to conform Medicare supplement policies and certificates to the requirements of federal law. Such regulations may include but need not be limited to: (1) Requiring refunds or credits if the policies or certificates do not meet loss ratio requirements; (2) establishing a uniform methodology for calculating and reporting loss ratios; (3) assuring public access to policies, premiums and loss ratio information of issuers of Medicare supplement insurance; (4) establishing a process for approving or disapproving policy forms, certificate forms and proposed premium increases; (5) establishing a policy for holding public hearings prior to approval of premium increases; and (6) establishing standards for Medicare select policies and certificates.

      (j) The commissioner may adopt regulations, in accordance with chapter 54, that specify prohibited policy provisions not otherwise specifically authorized which in the opinion of the commissioner, are unjust, unfair or unfairly discriminatory to any person insured or proposed to be insured under a Medicare supplement policy or certificate.

      (k) Medicare supplement policies shall return to policyholders benefits which are reasonable in relation to the premiums charged. The commissioner shall adopt regulations, in accordance with chapter 54, to establish minimum standards for loss ratios of Medicare supplement policies on the basis of incurred claim experience, or incurred health care expenses where coverage is provided by a health care center on a service rather than a reimbursement basis, and earned premiums in accordance with accepted actuarial principles and practices.

      (l) (1) In order to provide for full and fair disclosure in the sale of Medicare supplement policies, no Medicare supplement policy or certificate shall be delivered in this state unless an outline of coverage is delivered to the applicant at the time application is made.

      (2) The commissioner shall adopt regulations in accordance with the provisions of chapter 54 to prescribe the format and content of the outline of coverage required by this subsection. For purposes of this subsection, "format" means style, arrangements and overall appearance, including such items as the size, color and prominence of type and arrangement of text and captions. The outline of coverage shall include: (A) A description of the principal benefits and coverage provided in the policy; (B) a statement of the renewal provisions, including any reservation by the issuer of a right to change premiums; and (C) a statement that the outline of coverage is a summary of the policy issued or applied for and that the policy should be consulted to determine the governing contractual provisions.

      (3) The commissioner may prescribe by regulation a standard form and the contents of an informational brochure for persons eligible for Medicare, which is intended to improve the buyer's ability to select the most appropriate coverage and improve the buyer's understanding of Medicare. Except for direct response insurance policies, the commissioner may require by regulation that the informational brochure be provided to any prospective insured eligible for Medicare concurrently with the delivery of the outline of coverage. With respect to direct response insurance policies, the commissioner may require by regulation that the prescribed brochure be provided upon request to any prospective insured eligible for Medicare, but in no event later than the time of policy delivery.

      (4) The commissioner may adopt regulations, in accordance with chapter 54, for captions or notice requirements, determined to be in the public interest and designed to inform the prospective insured that particular insurance coverages are not Medicare supplement coverages, for all accident and sickness insurance policies sold to persons eligible for Medicare, other than: (A) Medicare supplement policies; or (B) disability income policies.

      (5) The commissioner may adopt regulations, in accordance with chapter 54, to govern the full and fair disclosure of the information in connection with the replacement of accident and sickness policies, subscriber contracts or certificates by persons eligible for Medicare.

      (m) Medicare supplement policies and certificates shall have a notice prominently printed on the first page of the policy or certificate or attached thereto stating in substance that the applicant shall have the right to return the policy or certificate within thirty days of its delivery and to have the premium refunded if, after examination of the policy or certificate, the applicant is not satisfied for any reason. Any refund made pursuant to this section shall be paid directly to the applicant by the issuer in a timely manner.

      (n) Every issuer of Medicare supplement insurance policies or certificates in this state shall provide a copy of any Medicare supplement advertisement intended for use in this state, whether through written, radio or television medium to the commissioner for his review or approval to the extent required by regulations, adopted pursuant to section 38a-819.

      (o) In addition to any other applicable penalties for violations of this title, the commissioner may require issuers violating any provision of this section or any regulations promulgated pursuant to this section to cease marketing any Medicare supplement policies or certificates in this state which is related directly or indirectly to a violation or take such actions as are necessary to comply with the provisions of this section, or both.

      (P.A. 92-111, S. 1, 4; P.A. 93-390, S. 6, 8; P.A. 97-57, S. 1-4.)

      History: P.A. 93-390 amended Subsec. (l) by deleting provision requiring outline of coverage to include automatic renewal premium increases in policyholders' premiums based on age, effective January 1, 1994; P.A. 97-57 amended Subdiv. (7) of Subsec. (a) to delete reference to Section 1833 of the federal Social Security Act and replaced "demonstration project authorized pursuant to amendments to the federal Social Security Act" with "demonstration project specified in 42 USC Section 1395ss(g)(1), amended Subsec. (d) to make subsection subject to Subdiv. (4) of Subsec. (l) of section and amended Subdiv. (4) of Subsec. (l) to delete reference to policies issued by reason of age, and to delete Subparas. (C) and (D), effective May 14, 1997.

      See Sec. 38a-495 re Medicare supplement policies and certificates.

      See Sec. 38a-522 re group Medicare supplement policies and certificates.

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      Sec. 38a-495b. Medicare supplement policies and certificates. Definitions. (a) As used in sections 38a-473, 38a-474 and 38a-481, subsection (l) of section 38a-495a, sections 38a-495c and 38a-513 and this section, "Medicare" means the Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965, as amended (Title I, Part I of P.L. 89-97). For policies or certificates delivered or issued for delivery to any resident of this state who is eligible for Medicare, prior to July 30, 1992, "Medicare supplement policy" means any individual or group health insurance policy or certificate delivered or issued for delivery to any resident of the state who is eligible for Medicare, except any long-term care policy as defined in sections 38a-501 and 38a-528. For policies or certificates delivered or issued for delivery to any resident on or after July 30, 1992, "Medicare supplement policy" means (A) a group or individual policy of accident and sickness insurance or (B) a subscriber contract of hospital and medical service corporations or health care centers, other than a policy issued pursuant to a contract under Section 1876 or Section 1833 of the federal Social Security Act (42 USC Section 1395 et seq.), or (C) an issued policy under a demonstration project authorized pursuant to amendments to the federal Social Security Act, which is advertised, marketed or designed primarily as a supplement to reimbursements under Medicare for the hospital, medical or surgical expenses of persons eligible for Medicare.

      (b) In accordance with the regulations adopted pursuant to section 38a-495a, on and after July 30, 1992, there are ten standardized Medicare supplement insurance policies or certificates designated as plans "A" to "J", inclusive.

      (P.A. 93-390, S. 1, 8.)

      History: P.A. 93-390 effective January 1, 1994.

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      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. (a) Any insurance company, fraternal benefit society, hospital service corporation, medical service corporation, health care center or any other entity in this state, on or after January 1, 1994, which delivers, issues for delivery, continues or renews any Medicare supplement insurance policies or certificates shall base the premium rates charged on a community rate. Such rate shall not be based on age, gender, previous claims history or the medical condition of the person covered by such policy or certificate. Except as provided in subsection (c) of this section, coverage shall not be denied on the basis of age, gender, previous claim history or the medical condition of the person covered by such policy or certificate, 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.

      (b) Nothing in this section shall prohibit an insurance company, fraternal benefit society, hospital service corporation, medical service corporation, health care center or any other entity in this state issuing Medicare supplement insurance policies or certificates from using its usual and customary underwriting procedures, provided no such company, society, corporation, center or other entity shall issue a Medicare supplement policy or certificate based on the age, gender, previous claims history or the medical condition of the applicant, except that the 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 for plans "H" to "J", inclusive.

      (c) Nothing in this section shall prohibit an insurance company, fraternal benefit society, hospital service corporation, medical service corporation, health care center or any other entity in this state when granting coverage under a Medicare supplement policy or certificate from excluding benefits for losses incurred within six months from the effective date of coverage based on a preexisting condition, in accordance with section 38a-495a and the regulations adopted pursuant to section 38a-495a.

      (d) Every insurance company, fraternal benefit society, hospital service corporation, medical service corporation, health care center or other entity in the state issuing Medicare supplement policies or certificates for plan "A", "B" or "C", or any combination thereof, to persons eligible for Medicare by reason of age, shall offer for sale the same such policies or certificates to persons eligible for Medicare by reason of disability.

      (e) Every insurance company, fraternal benefit society, hospital service corporation, medical service corporation, health care center or other entity in the state issuing Medicare supplement policies or certificates shall make all necessary arrangements with the Medicare Part B carrier and all Medicare Part A intermediaries to allow for the forwarding, to the issuing entity, of all Medicare claims containing the name of the entity issuing a Medicare supplement policy or certificate and the identification number of an insured. The entity issuing the Medicare supplement policy or certificate shall process all benefits available to an insured from a Medicare claim so forwarded, without requiring any additional action on the part of the insured.

      (f) The provisions of this section shall apply to all Medicare supplement policies or certificates issued on and after January 1, 1994. For Medicare supplement policies or certificates issued prior to January 1, 1994, the provisions of this section shall apply as of the first rating period commencing on or after January 1, 1994, but no later than January 1, 1995.

      (g) The Insurance Commissioner shall adopt such regulations as he deems necessary, in accordance with chapter 54, to carry out the purposes of this section.

      (P.A. 93-390, S. 2, 8; Oct. Sp. Sess. P.A. 93-1, S. 1, 2; P.A. 98-32.)

      History: P.A. 93-390 effective January 1, 1994; Oct. Sp. Sess. P.A. 93-1 inserted new Subsec. (c) re exclusion of benefits for losses incurred within six months from the effective date of coverage based on a preexisting condition and relettered the remaining Subsecs. accordingly, effective January 1, 1994 (Revisor's note: In Subsecs. (d) and (e) the references to "other entities in the state" were changed editorially by the Revisors to "other entity in the state" for consistency with the language in Subsecs. (a), (b) and (c)); P.A. 98-32 amended Subsec. (d) to require those who issue Medicare supplements for plans "A", "B" or "C", or any combination thereof, on the basis of age to offer the same policy to persons eligible for Medicare by reason of disability, and deleted requirement that companies which issue Medicare supplements on basis of age must offer at least one such policy on basis of disability.

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      Sec. 38a-496. (Formerly Sec. 38-174q). Coverage for occupational therapy. Definitions. Benefits. (a) For the purposes of this section:

      (1) "Occupational therapy" means services provided by a licensed occupational therapist in accordance with a plan of care established and approved in writing by a physician licensed in accordance with the provisions of chapter 370, who has certified that the prescribed care and treatment are not available from sources other than a licensed occupational therapist and which are provided in private practice or in a licensed health care facility. Such plan shall be reviewed and certified at least every two months by such physician.

      (2) "Health care facility" means an institution which provides occupational therapy, including, but not limited to, an outpatient clinic, a rehabilitative agency and a skilled or intermediate nursing facility.

      (3) "Rehabilitative agency" means an agency which provides an integrated multitreatment program designed to upgrade the function of handicapped disabled individuals by bringing together, as a team, specialized personnel from various allied health fields.

      (4) "Partial hospitalization" means a formal program of care provided in a hospital or facility for periods of less than twenty-four hours a day.

      (b) Every individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469 delivered, issued for delivery or renewed in this state on or after October 1, 1982, which provides coverage for expenses incurred for physical therapy shall provide coverage for occupational therapy provided in private practice or in a health care facility or in a partial hospitalization program on an exchange basis.

      (P.A. 82-148; P.A. 90-243, S. 86.)

      History: P.A. 90-243 substituted reference to health insurance policies for reference to hospital and medical expense policies or contracts in Subsec. (b) and specified applicability solely to individual policies; Sec. 38-174q transferred to Sec. 38a-496 in 1991.

      See Sec. 38a-524 for similar provisions re group policies.

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      Sec. 38a-497. (Formerly Sec. 38-174r). Termination of coverage of children in individual policies. Every individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469 delivered, issued for delivery, amended or renewed in this state on or after October 1, 1982, shall provide that coverage of a child shall terminate no earlier than the policy anniversary date on or after whichever of the following occurs first, the date on which the child marries, ceases to be a dependent of the policyholder, attains the age of nineteen if the child is not a full-time student at an accredited institution, or attains the age of twenty-three if the child is a full-time student at an accredited institution.

      (P.A. 82-143; P.A. 90-243, S. 87.)

      History: P.A. 90-243 substituted reference to health insurance policies for reference to hospital or medical expense policies and contracts and specified applicability solely to individual policies; Sec. 38-174r transferred to Sec. 38a-497 in 1991.

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      Sec. 38a-497a. Group coverage and benefits of a noncustodial parent. National Medical Support Notice. Notification of new employer by IV-D agency. Notification to custodial parent. Enrollment of child. (a) As used in this section (1) "insurer" shall have the same meaning as "insurer", as defined in 42 USC S 1396g-l(b), as including a group health plan, as defined in 29 USC S 1167(1), an employee welfare benefit plan providing medical care to participants or beneficiaries directly or through insurance reimbursement, or otherwise, a health maintenance organization and an entity offering a service benefit plan, and (2) "NMSN" means a National Medical Support Notice issued in a Title IV-D support case pursuant to section 46b-88.

      (b) If a child has health insurance coverage through an insurer of a noncustodial parent, such insurer shall: (1) Provide such information to the custodial parent as may be necessary for the child to obtain benefits through such coverage; (2) permit the custodial parent, or the health care provider, with the custodial parent's approval, to submit claims for covered services without the approval of the noncustodial parent; (3) make payments on claims submitted in accordance with this section directly to the custodial parent, the health care provider or the Department of Social Services; and (4) comply with the terms of any applicable NMSN.

      (c) An insurer shall not deny enrollment of a child under the group health plan of the child's parent if: (1) The child was born out of wedlock, provided the father of the child has acknowledged paternity pursuant to section 46b-172 or has been adjudicated the father pursuant to section 46b-171; (2) the child is not claimed as a dependent on the federal income tax return of the parent; (3) the child does not reside with the parent or in the insurer's service area; or (4) if the child is receiving, or is eligible for benefits under a state medical assistance plan required by the Social Security Act.

      (d) If a parent is required by a court or family support magistrate to provide health coverage for a child, and the parent is eligible for family health coverage, the insurer shall permit the parent to enroll, or shall enroll pursuant to any applicable NMSN, under the family coverage, a child who is otherwise eligible for such coverage without regard to any open enrollment restrictions. If enrollment of a child is dependent on the enrollment of a participant who is not enrolled, both the child and the participant shall be enrolled. If the parent is enrolled for coverage but fails to make application to obtain coverage for a child, the insurer shall enroll such child under family coverage upon application of such child's other parent, the state agency administering the Medicaid program or the state agency administering Title IV-D of the Social Security Act, or upon receipt of a NMSN, as provided in section 46b-88. The insurer shall not disenroll or eliminate coverage of such child unless the insurer is provided with satisfactory written evidence that the court or administrative order is no longer in effect or the child is enrolled or shall be enrolled in comparable health coverage through another insurer which shall take effect no later than the effective date of such disenrollment, or the employer eliminates family health coverage for all its employees.

      (e) If a parent is required by a court or an administrative order to provide health coverage for a child and the parent is eligible for family health coverage through an employer doing business in the state, such employer shall permit such parent to enroll such child under such coverage without regard to any open enrollment restrictions. If a parent is enrolled but fails to make application to obtain coverage of a child, the employer shall enroll such child under health care coverage upon application by the child's other parent or by the Commissioner of Social Services, or his designee, when such child is eligible under the Medicaid program or is receiving child support enforcement services pursuant to Title IV-D of the Social Security Act. A NMSN shall constitute an application for health care coverage by the issuing agency. If a noncustodial parent in a IV-D case provides such coverage and changes employment, and the new employer provides health care coverage, the IV-D agency or an agency under cooperative agreement therewith shall transfer notice of the provision for health care coverage to such new employer, as provided in section 46b-88. The notice shall operate to enroll the child in the noncustodial parent's health care plan if that portion of the obligor's income which is subject to withholding pursuant to subsection (e) of section 52-362, is sufficient to cover both the support order and health care coverage. At the time notice is transferred to the employer, the IV-D agency, or an agency under cooperative agreement therewith, shall also cause a copy of the notice of such transfer of health care coverage to be delivered to the obligor and to the custodial parent. The noncustodial parent may contest such notice by filing a motion for modification with the family support magistrate. An employer, subject to the provisions of this section, shall not disenroll or eliminate coverage of any such child unless the employer is provided satisfactory written evidence that: (1) A court or an administrative order for health care coverage is no longer in effect; (2) the child is or shall be enrolled in comparable health care coverage which shall take effect not later than the effective date of such disenrollment or elimination; or (3) the employer has eliminated family health care coverage for all of its employees.

      (May Sp. Sess. P.A. 94-5, S. 4, 30; P.A. 95-305, S. 1, 6; June 18 Sp. Sess. P.A. 97-7, S. 15, 38; P.A. 98-27, S. 16; May 9 Sp. Sess. P.A. 02-7, S. 41.)

      History: May Sp. Sess. P.A. 94-5 effective July 1, 1994; P.A. 95-305 inserted new Subsec. (a) defining "insurer", relettering existing provisions as Subsec. (b) and added Subsecs. (c), (d) and (e) which provide requirements for the enrollment of a child in a parent's health plan, deleted former Subsec. (b) re adoption of regulations and made technical changes, effective July 1, 1995; June 18 Sp. Sess. P.A. 97-7 amended Subsec. (e) by adding provision re notification of new employer of noncustodial parent and notification of obligor and custodial parent re transfer of health insurance coverage and contest by noncustodial parent, effective July 1, 1997; P.A. 98-27 made a technical change in Subsec. (e); May 9 Sp. Sess. P.A. 02-7 amended Subsec. (a) by designating definition of "insurer" as Subdiv. (1), making a technical change therein and adding Subdiv. (2) defining "NMSN", amended Subsec. (b) by adding Subdiv. (4) re compliance with NMSN, amended Subsec. (c) by changing "health plan" to "group health plan" and adding Subdiv. (4) re benefits under state medical assistance plan, amended Subsec. (d) by adding provisions re enrollment pursuant to and receipt of NMSN, enrollment dependent upon enrollment of participant and elimination of family health coverage by employer, and amended Subsec. (e) by adding provision re NMSN as application for health care coverage and reference to Sec. 46b-88.

      See Sec. 46b-88 re National Medical Support Notice.

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      Sec. 38a-498. (Formerly Sec. 38-174t). Mandatory coverage for medically necessary ambulance services. Direct payment to ambulance provider. (a) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed or amended in this state on or after October 1, 2002, shall provide coverage for medically necessary ambulance services for persons covered by the policy. The hospital policy shall be primary if a person is covered under more than one policy. The policy shall, as a minimum requirement, cover such services whenever any person covered by the contract is transported when medically necessary by ambulance to a hospital. Such benefits shall be subject to any policy provision which applies to other services covered by such policies. Notwithstanding any other provision of this section, such policies shall not be required to provide benefits in excess of the maximum allowable rate established by the Department of Public Health in accordance with section 19a-177.

      (b) (1) Each such individual health insurance policy shall provide that any payment by such company, corporation or center for emergency ambulance services under coverage required by this section shall be paid directly to the ambulance provider rendering such service if such provider has complied with the provisions of this subsection and has not received payment for such service from any other source.

      (2) Any ambulance provider submitting a bill for direct payment pursuant to this section shall stamp the following statement on the face of each bill: "NOTICE: This bill subject to mandatory assignment pursuant to Connecticut general statutes".

      (3) This subsection shall not apply to any transaction between an ambulance provider and an insurance company, hospital or medical service corporation, health care center or other entity if the parties have entered into a contract providing for direct payment.

      (P.A. 83-325; P.A. 84-375, S. 2, 4; P.A. 90-243, S. 88; P.A. 94-239, S. 1; P.A. 02-124, S. 1.)

      History: P.A. 84-375 amended Subsec. (a) to provide that on and after March 1, 1984, each hospital or medical expense insurance policy or hospital or medical service plan contract shall provide such coverage for ambulance services, that with more than one policy or contract, the hospital policy or contract shall be primary, that the benefits shall be subject to applicable policy or contract provisions, and five hundred dollars shall be the maximum mandatory benefit and added Subsec. (b), mandating direct payment to ambulance providers who meet certain requirements; P.A. 90-243 substituted reference to health insurance policies for reference to hospital and medical expense policies and contracts, deleted former Subsec. (b)(1) re group policies and designated former Subdivs. (2) and (3) as (1) and (2); Sec. 38-174t transferred to Sec. 38a-498 in 1991; P.A. 94-239 substituted "medically necessary" for "emergency" ambulance services and deleted the provision that the patient be admitted to the hospital; P.A. 02-124 amended Subsec. (a) to substitute "each" for "every", rewrite provisions re policies renewed or amended in this state, substitute "October 1, 2002" for "March 1, 1984", and substitute the maximum allowable rate established by the Department of Public Health for five hundred dollars re the maximum required coverage, inserted new Subsec. (b)(1) re direct payment for provider who complies with subsection, renumbered Subsecs. (b)(1) and (b)(2) as Subsecs. (b)(2) and (b)(3), respectively, and amended Subsec. (b)(3) to add "health care center or other entity".

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      Sec. 38a-498a. Preauthorization prohibited for certain 9-1-1 emergency calls. No individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469, delivered, issued for delivery or renewed in this state, on or after October 1, 1996, shall direct or require an enrollee to obtain approval from the insurer or health care center prior to calling a 9-1-1 local prehospital emergency medical service system whenever such enrollee is confronted with a life or limb threatening emergency. For purposes of this section, a "life or limb threatening emergency" means any event which the enrollee believes threatens his life or limb in such a manner that a need for immediate medical care is created to prevent death or serious impairment of health.

      (P.A. 96-67, S. 1.)

      History: (Revisor's note: In codifying public act 96-67 an incorrect reference to "of subsection (a)" appearing before the reference to "section 38a-469" was deleted editorially by the Revisors).

      See Sec. 38a-525a for similar provisions re group policies.

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      Sec. 38a-499. (Formerly Sec. 38-174v). Mandatory coverage for services of physician assistants and certain nurses. (a) For the purposes of this section:

      (1) "Certified nurse practitioner" means any registered nurse licensed under chapter 378 who has completed a formal educational nurse practitioner program and is certified by the American Nurses' Association, the National Board of Pediatric Nurse Practitioners and Associates or the Nurses' Association of the American College of Obstetricians and Gynecologists;

      (2) "Certified psychiatric-mental health clinical nurse specialist" means any registered nurse licensed under chapter 378 who has completed a formal educational program as a psychiatric-mental health clinical nurse specialist and is certified by the American Nurses' Association;

      (3) "Certified nurse-midwife" means any individual certified as nurse-midwife pursuant to sections 20-86a to 20-86e, inclusive;

      (4) "Physician assistant" means an individual licensed pursuant to section 20-12b.

      (b) Every individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469 delivered, issued for delivery or renewed in this state on or after October 1, 1984, shall provide coverage for the services of physician assistants, certified nurse practitioners, certified psychiatric-mental health clinical nurse specialists and certified nurse-midwives if such services are within the individual's area of professional competence as established by education and licensure or certification and are currently reimbursed when rendered by any other licensed health care provider. Subject to the provisions of chapter 378 and sections 20-86a to 20-86e, inclusive, no insurer, hospital or medical service corporation or health care center may require signature, referral or employment by any other health care provider as a condition of reimbursement, provided no insurer, hospital or medical service corporation or health care center may be required to pay for duplicative services actually rendered by both a physician assistant or a certified registered nurse and any other health care provider. The payment of such benefits shall be subject to any policy provisions which apply to other licensed health practitioners providing the same services. Nothing in this section may be construed as permitting (1) any registered nurse to perform or provide services beyond the scope of practice permitted in chapter 378 and sections 20-86a to 20-86e, inclusive, or (2) any physician assistant to perform or provide services beyond the scope of practice permitted in chapter 370.

      (P.A. 84-231; P.A. 90-243, S. 89; P.A. 95-74, S. 7, 9.)

      History: P.A. 90-243 substituted references to "health insurance policy" for references to hospital and medical expense policies and contracts, applied provisions to health care centers and specified applicability solely to individual policies; Sec. 38-174v transferred to Sec. 38a-499 in 1991; P.A. 95-74 added physician assistants to those whose services must be included in coverage and defined "physician assistant", effective July 1, 1995.

      See Sec. 38a-526 for similar provisions re group policies.

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      Sec. 38a-500. (Formerly Sec. 38-174w). Mandatory coverage for partners, sole proprietors and corporate officers for work-related injuries. Subrogation rights. (a) Notwithstanding any other provision of the general statutes to the contrary, no individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469 delivered, issued for delivery, amended or renewed on or after October 1, 1984, in this state may exclude coverage for a bodily injury solely because it was caused by an accident arising out of and in the course of employment to a covered individual who is: (1) A sole proprietor or business partner who is not covered by the provisions of chapter 568 or who accepts the provisions of chapter 568 pursuant to subdivision (10) of section 31-275; or (2) an employee of a corporation and who is a corporate officer, regardless of any election by such individual to be excluded from coverage under chapter 568 pursuant to subparagraph (B)(v) of subdivision (9) of section 31-275. The provisions of this section shall also apply to all such policies or contracts in this state as of the first anniversary date of such policy or contract on or after October 1, 1984. The payment of benefits pursuant to this section shall be subject to any policy or contract provisions which apply to a claim not resulting from bodily injury caused by an accident arising out of and in the course of employment.

      (b) Whenever any such covered individual who receives benefits for any such injury under such policy or contract has a right of recovery or reimbursement against any person or organization, any carrier that has paid such benefits to or for the individual shall be subrogated to all such rights of recovery or reimbursement to the extent of its payment. Such carrier shall also have a lien on the proceeds of any award or approval of any compromise made by a workers' compensation commissioner pursuant to the individual's workers' compensation claim, in accordance with the provisions of section 38a-470.

      (P.A. 84-499, S. 1; P.A. 90-243, S. 90.)

      History: P.A. 90-243 substituted reference to health insurance policies for hospital and medical expense policies and contracts, specified applicability to individual policies only and made technical grammatical change; Sec. 38-174w transferred to Sec. 38a-500 in 1991; (Revisor's note: In 1997 the phrase "type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) section 38a-469 delivered," was changed editorially by the Revisors to "type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469 delivered," to correct a clerical error).

      See Sec. 38a-527 for similar provisions re group policies.

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      Sec. 38a-501. (Formerly Sec. 38-174x). Long-term care policies. (a) As used in this section, "long-term care policy" means any individual health insurance policy, delivered or issued for delivery to any resident of this state on or after July 1, 1986, which is designed to provide, within the terms and conditions of the policy, benefits on an expense-incurred, indemnity or prepaid basis for necessary care or treatment of an injury, illness or loss of functional capacity provided by a certified or licensed health care provider in a setting other than an acute care hospital, for at least one year after a reasonable elimination period. A long-term care policy shall provide benefits for confinement in a nursing home or confinement in the insured's own home or both. Any additional benefits provided shall be related to long-term treatment of an injury, illness or loss of functional capacity. "Long-term care policy" shall not include any such policy which is offered primarily to provide basic Medicare supplement coverage, basic medical-surgical expense coverage, hospital confinement indemnity coverage, major medical expense coverage, disability income protection coverage, accident only coverage, specified accident coverage or limited benefit health coverage.

      (b) No insurance company, fraternal benefit society, hospital service corporation, medical service corporation or health care center may deliver or issue for delivery any long-term care policy which has a loss ratio of less than sixty per cent for any individual long-term care policy. An issuer shall not use or change premium rates for a long-term care insurance policy unless the rates have been filed with and approved by the Insurance Commissioner. Any rate filings or rate revisions shall demonstrate that anticipated claims in relation to premiums when combined with actual experience to date can be expected to comply with the loss ratio requirement of this section.

      (c) No such company, society, corporation or center may deliver or issue for delivery any long-term care policy without providing, at the time of solicitation or application for purchase or sale of such coverage, full and fair disclosure of the benefits and limitations of the policy.

      (d) The Insurance Commissioner shall adopt regulations, in accordance with chapter 54, which address (1) the insured's right to information prior to his replacing an accident and sickness policy with a long-term care policy, (2) the insured's right to return a long-term care policy to the insurer, within a specified period of time after delivery, for cancellation, and (3) the insured's right to accept by his signature, and prior to it becoming effective, any rider or endorsement added to a long-term care policy after the issuance date of such policy. The Insurance Commissioner shall adopt such additional regulations as he deems necessary in accordance with chapter 54 to carry out the purpose of this section.

      (e) The Insurance Commissioner may, upon written request by any such company, society, corporation or center, issue an order to modify or suspend a specific provision of this section or any regulation adopted pursuant thereto with respect to a specific long-term care policy upon a written finding that: (1) The modification or suspension would be in the best interest of the insureds; (2) the purposes to be achieved could not be effectively or efficiently achieved without such modification or suspension; and (3)(A) the modification or suspension is necessary to the development of an innovative and reasonable approach for insuring long-term care, (B) the policy is to be issued to residents of a life care or continuing care retirement community or other residential community for the elderly and the modification or suspension is reasonably related to the special needs or nature of such community, or (C) the modification or suspension is necessary to permit long-term care policies to be sold as part of, or in conjunction with, another insurance product, whenever the commissioner decides not to issue such an order, he shall provide written notice of such decision to the requesting party in a timely manner.

      (f) Upon written request by any such company, society, corporation or center, the Insurance Commissioner may issue an order to extend the preexisting condition exclusion period, as established by regulations adopted pursuant to this section, for purposes of specific age group categories in a specific long-term care policy form whenever he makes a written finding that such an extension is in the best interest to the public. Whenever the commissioner decides not to issue such an order, he shall provide written notice of such decision to the requesting party in a timely manner.

      (g) The provisions of section 38a-19 shall be applicable to any such requesting party aggrieved by any order or decision of the commissioner made pursuant to subsections (e) and (f) of this section.

      (P.A. 86-49, S. 2, 3; P.A. 89-236, S. 1, 3; P.A. 90-82; 90-243, S. 91; P.A. 91-276, S. 1; P.A. 94-39, S. 5.)

      History: P.A. 89-236 amended Subsec. (a) further defining "long-term care policy", amended Subsec. (c) excluding policies issued to certain groups from disclosure requirement, amended Subsec. (d) detailing regulations to be adopted, added Subsec. (e) providing modification or suspension of requirements under certain conditions, added Subsec. (f) providing extension of preexisting condition exclusion period under certain conditions and added Subsec. (g) re appeal of commissioner's rulings; P.A. 90-82 allowed an insured the choice of a long-term care policy which provides benefits for confinement in the insured's own home or a policy which allows coverage for both nursing home and own home care where previously coverage was limited to nursing home care; P.A. 90-243 substituted reference to health insurance policies for reference to accident and sickness policies and deleted provisions concerning group coverage; Sec. 38-174x transferred to Sec. 38a-501 in 1991; P.A. 91-276 substituted "sixty per cent" for "fifty-five per cent" in Subsec. (b) re loss ratio for any individual long-term care policy; P.A. 94-39 amended Subsec. (b) by adding provision to require that issuer not use or change premium rates for a long-term policy without the filing and approval of the insurance commissioner and that such filing or revision comply with the loss ratio requirement for any individual long-term care policy.

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      Sec. 38a-502. (Formerly Sec. 38-174ff). Mandatory coverage for services provided by the Veterans' Home. No individual health insurance policy delivered, issued for delivery or renewed in this state on or after October 1, 1988, may exclude coverage for services provided by the Veterans' Home.

      (P.A. 88-68; P.A. 90-243, S. 92; P.A. 04-169, S. 18.)

      History: P.A. 90-243 substituted reference to health insurance policies for reference to hospital and medical expense policies and contracts and made technical grammatical change; Sec. 38-174ff transferred to Sec. 38a-502 in 1991; P.A. 04-169 changed the name of the Veterans' Home and Hospital to the Veterans' Home, effective June 1, 2004.

      See Sec. 38a-529 for similar provisions re group policies.

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      Sec. 38a-503. (Formerly Sec. 38-174gg). Mandatory coverage for mammography. Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state on or after October 1, 2001, shall provide benefits for mammographic examinations to any woman covered under the policy which are at least equal to the following minimum requirements: (1) A baseline mammogram for any woman who is thirty-five to thirty-nine years of age, inclusive; and (2) a mammogram every year for any woman who is forty years of age or older. Such benefits shall be subject to any policy provisions which apply to other services covered by such policy.

      (P.A. 88-124, S. 1; P.A. 90-243, S. 93; P.A. 01-171, S. 22.)

      History: P.A. 90-243 substituted reference to health insurance policies for references to hospital or medical expense policies and contracts and specified applicability solely to individual policies; Sec. 38-174gg transferred to Sec. 38a-503 in 1991; P.A. 01-171 added "amended or continued" re policies in this state, substituted "October 1, 2001," for "October 1, 1988," re policy date, consolidated Subdivs. (2) and (3) to provide annual coverage for any woman who is forty or over rather than coverage every two years for women forty to forty-nine and annually thereafter, and substituted "each" for "every".

      See Sec. 38a-530 for similar provisions re group policies.

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      Sec. 38a-503a. Mandatory coverage for breast cancer survivors. (a) No individual health insurance plan, as defined in subdivision (1) of subsection (a) of section 38a-476, or insurance arrangement, as defined in subdivision (2) of subsection (a) of section 38a-476, may refuse to cover an individual health insurance applicant due to breast cancer if such applicant has remained free from breast cancer for at least five years prior to the applicant's request for individual health insurance coverage. The individual health insurance carrier may require that the applicant submit to a physical examination.

      (b) The provisions of this section shall apply to every health insurance plan or insurance arrangement issued, renewed or continued in this state on or after October 1, 1996. For purposes of this section, the date a plan or arrangement is continued shall be the anniversary date of the issuance of the plan or arrangement.

      (P.A. 96-177, S. 4.)

      See Sec. 38a-476(a) re breast cancer and preexisting conditions clauses.

      See Sec. 38a-530a for similar provisions re group policies.

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      Sec. 38a-503b. Carriers to permit direct access to obstetrician-gynecologist. (a) As used in this section, "carrier" means each insurer, health care center, hospital and medical service corporation or other entity delivering, issuing for delivery, renewing or amending any individual health insurance policy in this state on or after October 1, 1995, providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469.

      (b) Each carrier shall permit a female enrollee direct access to a participating in-network obstetrician-gynecologist for any gynecological examination or care related to pregnancy and shall allow direct access to a participating in-network obstetrician-gynecologist for primary and preventive obstetric and gynecologic services required as a result of any gynecological examination or as a result of a gynecological condition. Such obstetric and gynecologic services include, but are not limited to, pap smear tests. The plan may require the participating in-network obstetrician-gynecologist to discuss such services and any treatment plan with the female enrollee's primary care provider. Nothing in this section shall preclude access to an in-network nurse-midwife as licensed pursuant to sections 20-86c and 20-86g and in-network advanced practice nurses, as licensed pursuant to sections 20-93 and 20-94a for obstetrical and gynecological services within their scope of practice.

      (c) Each carrier may allow a female enrollee to designate either a participating, in-network obstetrician-gynecologist or any other in-network physician designated by the carrier as a primary care provider, or both, and may offer the same choice to all female enrollees.

      (P.A. 95-199, S. 1; P.A. 96-227, S. 14; P.A. 01-171, S. 18.)

      History: P.A. 96-227 amended Subsec. (a) to include Subdiv. (12) in its citation to Sec. 38a-469; P.A. 01-171 amended Subsec. (b) to provide that "such obstetric and gynecologic services include, but are not limited to, pap smear tests".

      See Sec. 38a-530b for similar provisions re group policies.

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      Sec. 38a-503c. Mandatory coverage for maternity care. Notice required. (a) As used in this section, "carrier" means each insurer, health care center, hospital and medical service corporation, or other entity delivering, issuing for delivery, renewing or amending any individual health insurance policy in this state on or after October 1, 1996, providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469.

      (b) Each individual health insurance carrier that offers maternity benefits shall provide coverage of a minimum of forty-eight hours of inpatient care for a mother and her newborn infant following a vaginal delivery and a minimum of ninety-six hours of inpatient care for a mother and her newborn infant following a caesarean delivery. The time periods shall commence at the time of delivery.

      (c) Any decision to shorten the length of inpatient stay to less than that provided under subsection (b) of this section shall be made by the attending health care providers after conferring with the mother.

      (d) If a mother and newborn are discharged pursuant to subsection (c) of this section, prior to the inpatient length of stay provided under subsection (b) of this section, coverage shall be provided for a follow-up visit within forty-eight hours of discharge and an additional follow-up visit within seven days of discharge. Such follow-up services shall include, but not be limited to, physical assessment of the newborn, parent education, assistance and training in breast or bottle feeding, assessment of the home support system and the performance of any medically necessary and appropriate clinical tests. Such services shall be consistent with protocols and guidelines developed by attending providers or by national pediatric, obstetric and nursing professional organizations for these services and shall be provided by qualified health care personnel trained in postpartum maternal and newborn pediatric care.

      (e) Each individual health insurance carrier shall provide notice to policyholders regarding the coverage required under this section. The notice shall be in writing and shall be transmitted at the earliest of either the next mailing to the policyholder, the yearly summary of benefits sent to the policyholder or January 1, 1997.

      (P.A. 96-177, S. 1, 6.)

      History: P.A. 96-177 effective May 24, 1996.

      See Sec. 38a-530c for similar provisions re group policies.

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      Sec. 38a-503d. Mandatory coverage for mastectomy care. Termination of provider contract prohibited. (a) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (10), (11) and (12) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state on or after July 1, 1997, shall provide coverage for at least forty-eight hours of inpatient care following a mastectomy or lymph node dissection, and shall provide coverage for a longer period of inpatient care if such care is recommended by the patient's treating physician after conferring with the patient. No such insurance policy may require mastectomy surgery or lymph node dissection to be performed on an outpatient basis. Outpatient surgery or shorter inpatient care is allowable under this section if the patient's treating physician recommends such outpatient surgery or shorter inpatient care after conferring with the patient.

      (b) No individual health insurance carrier may terminate the services of, require additional documentation from, require additional utilization review, reduce payments or otherwise penalize or provide financial disincentives to any attending health care provider on the basis that the provider orders care consistent with the provisions of this section.

      (P.A. 97-198, S. 1, 5.)

      History: P.A. 97-198 effective July 1, 1997.

      See Sec. 38a-530d for similar provisions re group policies.

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      Sec. 38a-503e. Mandatory coverage for prescription contraceptives. (a) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed or continued in this state on or after October 1, 1999, that provides coverage for outpatient prescription drugs approved by the federal Food and Drug Administration shall not exclude coverage for prescription contraceptive methods approved by the federal Food and Drug Administration.

      (b) (1) Notwithstanding any other provision of this section, any insurance company, hospital or medical service corporation, or health care center may issue to a religious employer an individual health insurance policy that excludes coverage for prescription contraceptive methods which are contrary to the religious employer's bona fide religious tenets.

      (2) Notwithstanding any other provision of this section, upon the written request of an individual who states in writing that prescription contraceptive methods are contrary to such individual's religious or moral beliefs, any insurance company, hospital or medical service corporation, or health care center may issue to the individual an individual health insurance policy that excludes coverage for prescription contraceptive methods.

      (c) Any health insurance policy issued pursuant to subsection (b) of this section shall provide written notice to each insured or prospective insured that prescription contraceptive methods are excluded from coverage pursuant to said subsection. Such notice shall appear, in not less than ten-point type, in the policy, application and sales brochure for such policy.

      (d) Nothing in this section shall be construed as authorizing an individual health insurance policy to exclude coverage for prescription drugs ordered by a health care provider with prescriptive authority for reasons other than contraceptive purposes.

      (e) Notwithstanding any other provision of this section, any insurance company, hospital or medical service corporation, or health care center which is owned, operated or substantially controlled by a religious organization which has religious or moral tenets which conflict with the requirements of this section may provide for the coverage of prescription contraceptive methods as required under this section through another such entity offering a limited benefit plan. The cost, terms and availability of such coverage shall not differ from the cost, terms and availability of other prescription coverage offered to the insured.

      (f) As used in this section, "religious employer" means an employer that is a "qualified church-controlled organization" as defined in 26 USC 3121 or a church-affiliated organization.

      (P.A. 99-79, S. 1.)

      See Sec. 38a-530e for similar provisions re group policies.

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      Sec. 38a-504. (Formerly Sec. 38-262i). Mandatory coverage for treatment of tumors and leukemia. Mandatory coverage for reconstructive surgery, prosthesis, chemotherapy and wigs. Mandatory coverage for breast reconstruction after mastectomy. (a) Each insurance company, hospital service corporation, medical service corporation, health care center or fraternal benefit society which delivers or issues for delivery in this state individual health insurance policies providing coverage of the type specified in subdivisions (1), (2), (4), (10), (11) and (12) of section 38a-469, shall provide coverage under such policies for the surgical removal of tumors and treatment of leukemia, including outpatient chemotherapy, reconstructive surgery, cost of any nondental prosthesis including any maxillo-facial prosthesis used to replace anatomic structures lost during treatment for head and neck tumors or additional appliances essential for the support of such prosthesis, outpatient chemotherapy following surgical procedure in connection with the treatment of tumors, and a wig if prescribed by a licensed oncologist for a patient who suffers hair loss as a result of chemotherapy. Such benefits shall be subject to the same terms and conditions applicable to all other benefits under such policies.

      (b) Except as provided in subsection (c) of this section, the coverage required by subsection (a) of this section shall provide at least a yearly benefit of five hundred dollars for the surgical removal of tumors, five hundred dollars for reconstructive surgery, five hundred dollars for outpatient chemotherapy, three hundred fifty dollars for a wig and three hundred dollars for prosthesis, except that for purposes of the surgical removal of breasts due to tumors the yearly benefit for prosthesis shall be at least three hundred dollars for each breast removed.

      (c) The coverage required by subsection (a) of this section shall provide benefits for the reasonable costs of reconstructive surgery on each breast on which a mastectomy has been performed, and reconstructive surgery on a nondiseased breast to produce a symmetrical appearance. Such benefits shall be subject to the same terms and conditions applicable to all other benefits under such policies. For the purposes of this subsection, reconstructive surgery includes, but is not limited to, augmentation mammoplasty, reduction mammoplasty and mastopexy.

      (P.A. 79-327, S. 2; P.A. 86-54; P.A. 87-40; 87-275, S. 2; P.A. 90-243, S. 94; P.A. 97-198, S. 3, 5; P.A. 98-27, S. 17; P.A. 04-34, S. 1.)

      History: P.A. 86-54 clarified the section by limiting its applicability to individual and group medical expense insurance policies and contract plans, rather than to all individual and group health insurance policies and contract plans; P.A. 87-40 amended Subsec. (c) to increase the minimum coverage requirement for prosthesis from two hundred to three hundred dollars; P.A. 87-275 amended Subsec. (c) to provide that the yearly benefit for prosthesis shall be at least three hundred dollars for each breast surgically removed due to tumors; P.A. 90-243 deleted former Subsec. (a) re group coverages, relettered the remaining Subsecs., added references to health care centers, substituted references to health insurance policies for references to medical expense policies or contracts; Sec. 38-262i transferred to Sec. 38a-504 in 1991; P.A. 97-198 added exception in Subsec. (b) and added new Subsec. (c) re breast reconstruction after mastectomy, effective July 1, 1997; P.A. 98-27 amended Subsec. (a) to delete reference to Subdiv. (6) of Sec. 38a-469; P.A. 04-34 amended Subsec. (a) to substitute "Each" for "Any" and require coverage for a wig if prescribed for a patient who suffers hair loss as a result of chemotherapy and amended Subsec. (b) to require a yearly benefit of three hundred fifty dollars for a wig.

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

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

      See Sec. 38a-542 for similar provisions re group policies.

      See Secs. 38a-595 to 38a-626, inclusive, 38a-631 to 38a-640, inclusive, and 38a-800 re fraternal benefit societies.

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      Sec. 38a-504a. Coverage for certain cancer clinical trials. Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery or renewed in this state on or after January 1, 2002, shall provide coverage for the routine patient care costs, as defined in section 38a-504d, associated with cancer clinical trials, in accordance with sections 38a-504b to 38a-504g, inclusive. As used in this section and sections 38a-504b to 38a-504g, inclusive, "cancer clinical trial" means an organized, systematic, scientific study of therapies, tests or other clinical interventions for purposes of treatment or palliation or therapeutic intervention for the prevention of cancer in human beings, except that a clinical trial for the prevention of cancer is eligible for coverage only if it involves a therapeutic intervention and is a phase III clinical trial approved by one of the entities identified in section 38a-504b and is conducted at multiple institutions.

      (P.A. 01-171, S. 8, 25.)

      History: P.A. 01-171 effective January 1, 2002.

      See Sec. 38a-542a for similar provisions re group policies.

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      Sec. 38a-504b. Cancer clinical trials that are eligible for coverage. In order to be eligible for coverage of routine patient care costs, as defined in section 38a-504d, a cancer clinical trial shall be conducted under the auspices of an independent peer-reviewed protocol that has been reviewed and approved by: (1) One of the National Institutes of Health; or (2) a National Cancer Institute affiliated cooperative group; or (3) the federal Food and Drug Administration as part of an investigational new drug or device exemption; or (4) the federal Department of Defense or Veterans Affairs. Nothing in sections 38a-504a to 38a-504g, inclusive, shall be construed to require coverage for any single institution cancer clinical trial conducted solely under the approval of the institutional review board of an institution, or any trial that is no longer approved by an entity identified in subdivision (1), (2), (3) or (4) of this section.

      (P.A. 01-171, S. 9, 25.)

      History: P.A. 01-171 effective January 1, 2002.

      See Sec. 38a-542b for similar provisions re group policies.

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      Sec. 38a-504c. Evidence and information re eligibility for cancer clinical trial. No coverage required for otherwise reimbursable costs. In order to be eligible for coverage of routine patient care costs, as defined in section 38a-504d, the insurer, health care center or plan administrator may require that the person or entity seeking coverage for the cancer clinical trial provide: (1) Evidence satisfactory to the insurer, health care center or plan administrator that the insured person receiving coverage meets all of the patient selection criteria for the cancer clinical trial, including credible evidence in the form of clinical or preclinical data showing that the cancer clinical trial is likely to have a benefit for the insured person that is commensurate with the risks of participation in the cancer clinical trial to treat the person's condition; and (2) evidence that the appropriate informed consent has been received from the insured person; and (3) copies of any medical records, protocols, test results or other clinical information used by the physician or institution seeking to enroll the insured person in the cancer clinical trial; and (4) a summary of the anticipated routine patient care costs in excess of the costs for standard treatment; and (5) information from the physician or institution seeking to enroll the insured person in the clinical trial regarding those items, including any routine patient care costs, that are eligible for reimbursement by an entity other than the insurer or health care center, including the entity sponsoring the clinical trial; and (6) any additional information that may be reasonably required for the review of a request for coverage of the cancer clinical trial. The health plan or insurer shall request any additional information about a cancer clinical trial within five business days of receiving a request for coverage from an insured person or a physician seeking to enroll an insured person in a cancer clinical trial. Nothing in sections 38a-504a to 38a-504g, inclusive, shall be construed to require the insurer or health care center to provide coverage for routine patient care costs that are eligible for reimbursement by an entity other than the insurer, including the entity sponsoring the cancer clinical trial.

      (P.A. 01-171, S. 10, 25.)

      History: P.A. 01-171 effective January 1, 2002.

      See Sec. 38a-542c for similar provisions re group policies.

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      Sec. 38a-504d. Cancer clinical trials: Routine patient care costs. (a) For purposes of sections 38a-504a to 38a-504g, inclusive, "routine patient care costs" means: (1) Coverage for medically necessary health care services that are incurred as a result of the treatment being provided to the insured person for purposes of the cancer clinical trial that would otherwise be covered if such services were not rendered pursuant to a cancer clinical trial. Such services shall include those rendered by a physician, diagnostic or laboratory tests, hospitalization or other services provided to the patient during the course of treatment in the cancer clinical trial for a condition, or one of its complications, that is consistent with the usual and customary standard of care and would be covered if the insured person were not enrolled in a cancer clinical trial; and (2) coverage for routine patient care costs incurred for drugs provided to the insured person, in accordance with section 38a-518b, provided such drugs have been approved for sale by the federal Food and Drug Administration.

      (b) Routine patient care costs shall be subject to the terms, conditions, restrictions, exclusions and limitations of the contract or certificate of insurance between the subscriber and the insurer or health plan, including limitations on out-of-network care. The insurer or health care center may require that any routine tests or services required under the cancer clinical trial protocol be performed by providers or institutions under contract with the insurer or health care center.

      (c) Notwithstanding the provisions of subsection (a) of this section, routine patient care costs shall not include: (1) The cost of an investigational new drug or device that has not been approved for market for any indication by the federal Food and Drug Administration; (2) the cost of a non-health-care service that an insured person may be required to receive as a result of the treatment being provided for the purposes of the cancer clinical trial; (3) facility, ancillary, professional services and drug costs that are paid for by grants or funding for the cancer clinical trial; (4) costs of services that (A) are inconsistent with widely accepted and established regional or national standards of care for a particular diagnosis, or (B) are performed specifically to meet the requirements of the cancer clinical trial; (5) costs that would not be covered under the insured person's policy for noninvestigational treatments, including, but not limited to, items excluded from coverage under the insured person's contract with the insurer or health plan; and (6) transportation, lodging, food or any other expenses associated with travel to or from a facility providing the cancer clinical trial, for the insured person or any family member or companion.

      (P.A. 01-171, S. 11, 25.)

      History: P.A. 01-171 effective January 1, 2002.

      See Sec. 38a-542d for similar provisions re group provisions.

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      Sec. 38a-504e. Cancer clinical trials: Billing. Payments. Appeals. (a) Providers, hospitals and institutions that provide routine patient care services as set forth in subsection (a) of section 38a-504d as part of a cancer clinical trial that meets the requirements of sections 38a-504a to 38a-504g, inclusive, and is approved for coverage by the insurer or health care center shall not bill the insurer or health care center or the insured person for any facility, ancillary or professional services or costs that are not routine patient care services as set forth in subsection (a) of section 38a-504d or for any product or service that is paid by the entity sponsoring or funding the cancer clinical trial.

      (b) Providers, hospitals, institutions and insured persons may appeal a health plan's denials of payment for services only to the extent permitted by the contract between the insurer or health care center and the provider, hospital or institution.

      (c) Providers, hospitals or institutions that have contracts with the insurer or health care center to render covered routine patient care services to insured persons as part of a cancer clinical trial may not bill the insured person for the cost of any covered routine patient care service.

      (d) Providers, hospitals or institutions that do not have a contract with the insurer or health care center to render covered routine patient care services to insured persons as part of a cancer clinical trial may not bill the insured person for the cost of any covered routine patient care service.

      (e) Nothing in this section shall be construed to prohibit a provider, hospital or institution from collecting a deductible or copayment as set forth in the insured person's contract for any covered routine patient care service.

      (f) Pursuant to subsection (b) of section 38a-504d, insurers or health care centers shall be required to pay providers, hospitals and institutions that do not have a contract with the insurer or health care center to render covered routine patient care services to insured persons the lesser of (1) the lowest contracted per diem, fee schedule rate or case rate that the insurer or health care center pays to any participating provider in the state of Connecticut for similar in-network services, or (2) the billed charges. Providers, hospitals or institutions may not collect any amount more than the total amount paid by the insurer or health care center and the insured person in the form of a deductible or copayment set forth in the insured person's contract. Such amount shall be deemed by the provider, hospital or institution to be payment in full.

      (P.A. 01-171, S. 12, 25.)

      History: P.A. 01-171 effective January 1, 2002.

      See Sec. 38a-542e for similar provisions re group policies.

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      Sec. 38a-504f. Cancer clinical trials: Standardized forms. Time frames for coverage determinations. Appeals. Regulations. (a) For purposes of cancer clinical trials, the Insurance Department, in cooperation with the Connecticut Oncology Association, the American Cancer Society, the Connecticut Association of Health Plans and Anthem Blue Cross of Connecticut, shall develop a standardized form that all providers, hospitals and institutions shall submit to the insurer or health care center when seeking to enroll an insured person in a cancer clinical trial. An insurer or health care center may not substitute any other approval request form for the form developed by the department, except that any insurer or health care center that has entered into an agreement to provide coverage for cancer clinical trials approved pursuant to section 38a-504g may use the form or process established by such agreement.

      (b) Any insurer or health care center that receives the department form from a provider, hospital or institution seeking coverage for the routine patient care costs of an insured person in a cancer clinical trial shall approve or deny coverage for such services within five business days of receiving such request and any other reasonable supporting materials requested by the insurer or health plan pursuant to section 38a-504c, except that an insurer or health care center that utilizes independent experts to review such requests shall respond within ten business days. Requests for coverage of phase III clinical trials for the prevention of cancer pursuant to section 38a-504a shall be approved or denied within fourteen business days.

      (c) The insured, or the provider with the insured's written consent, may appeal any denial of coverage for medical necessity to an external, independent review pursuant to section 38a-478n. Such external review shall be conducted by a properly qualified review agent whom the department has determined does not have a conflict of interest regarding the cancer clinical trial.

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

      (P.A. 01-171, S. 13, 25.)

      History: P.A. 01-171 effective January 1, 2002.

      See Sec. 38a-542f for similar provisions re group policies.

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      Sec. 38a-504g. Cancer clinical trials: Submission and certification of policy forms. (a) Any insurer or health care center with coverage policies for care in cancer clinical trials shall submit such policies to the Insurance Department for evaluation and approval. The department shall certify whether the insurer's or health care center's coverage policy for routine patient care costs associated with cancer clinical trials is substantially equivalent to the requirements of sections 38a-504a to 38a-504g, inclusive. If the department finds that such coverage is substantially equivalent to the requirements of sections 38a-504a to 38a-504g, inclusive, the insurer or health care center shall be exempt from the provisions of sections 38a-504a to 38a-504g, inclusive.

      (b) Any such insurer or health care center shall report annually, in writing, to the department that there have been no changes in the policy as certified by the department. If there has been any change in the policy, the insurer or health care center shall resubmit its policy for certification by the department.

      (c) Any insurer or health care center coverage policy found by the department not to be substantially equivalent to the requirements of sections 38a-504a to 38a-504g, inclusive, shall abide by the requirements of sections 38a-504a to 38a-504g, inclusive, until the insurer or health care center has received such certification by the department.

      (P.A. 01-171, S. 14, 25.)

      History: P.A. 01-171 effective January 1, 2002.

      See Sec. 38a-542g for similar provisions re group policies.

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      Sec. 38a-505. (Formerly Sec. 38-378). Insurance Commissioner's powers concerning comprehensive health care plans. Notification to purchasers of policy. In order to provide reasonable simplification of terms and coverages of individual health insurance policies, to facilitate public understanding and comparison, to eliminate provisions which may be misleading or unreasonably confusing in connection with either the purchase of such coverage or with the settlement of claims and to provide for full disclosure in the sale of such coverages:

      (a) The commissioner shall issue regulations to establish specific standards for policy provisions used in individual health insurance policies, but not including group conversion policies, which shall be in addition to and in accordance with sections 38a-80, 38a-321 to 38a-324, inclusive, 38a-326, 38a-329, 38a-334 to 38a-336a, inclusive, 38a-338 to 38a-358, inclusive, 38a-470 to 38a-472, inclusive, 38a-475, 38a-480 to 38a-503, inclusive, 38a-507, 38a-514, 38a-519, 38a-523, 38a-531, 38a-577 to 38a-590, inclusive, and 38a-802 to 38a-810, inclusive, and other applicable laws of this state which may cover the terms of renewability, initial and subsequent conditions of eligibility, nonduplication of coverage provisions, coverage of dependents, termination of insurance, probationary periods, limitations, exceptions, reductions, elimination periods, requirements for replacements, recurrent conditions, preexisting conditions, and the definition of the terms hospital, accident, sickness, injury, physician, accidental means, total disability, permanent disability, partial disability, nervous disorders, guaranteed renewable, and noncancellable.

      (b) The commissioner shall adopt regulations, in accordance with chapter 54, that specify prohibited policy provisions not otherwise specifically authorized by statute which in the opinion of the commissioner are unjust, unfair or unfairly discriminatory to the policyholder, any person insured under the policy, or any beneficiary.

      (c) The commissioner shall adopt regulations, in accordance with chapter 54, to establish minimum standards for benefits under each of the following categories of coverage in individual policies, other than conversion policies issued pursuant to a contractual conversion privilege under a group policy: Basic hospital expense coverage, basic medical-surgical expense coverage, hospital confinement indemnity coverage, major medical expense coverage, disability income protection coverage, accident only coverage and specified accident coverage. Specified disease policies, riders and benefits shall be prohibited whether issued on a group or individual basis, except as provided in section 38a-457, or as determined by the commissioner provided the commissioner, prior to permitting any sale of such policies, adopts regulations in accordance with chapter 54 to establish minimum standards for benefits in such specified disease policies, certificates, riders, endorsements and benefits.

      (d) Nothing in this section shall preclude the issuance of any policy which combines two or more of the categories of coverage enumerated in subsection (c), except that specified accident coverage shall not be combined with any other category of coverage. The commissioner shall prescribe the method of identification of policies based upon coverage provided.

      (e) No policy shall be delivered or issued for delivery in this state which does not meet the prescribed minimum standards for the categories of coverage listed in subsection (c), provided nothing in this section shall preclude the issuance or delivery of any policy which does not meet such prescribed minimum standards of coverage so long as such policy is clearly identified as not meeting such prescribed standards.

      (f) No such policy shall be delivered in this state unless: (1) An outline of coverage described herein accompanies the policy or (2) the outline of coverage described in this section is delivered to the applicant at the time application is made and acknowledgment of receipt of certificate of delivery of such outline is provided the carrier with the application. In the event the policy is issued on a basis other than that applied for, the outline of coverage properly describing the policy shall accompany the policy when it is delivered. The outline of coverage shall include: (A) A statement identifying the applicable category or categories of coverage provided by the policy in accordance with this section; (B) a description of the principal benefits and coverage provided in the policy; (C) a statement of the exceptions, reductions and limitations contained in the policy or contract; (D) a statement of the renewal provisions including any reservation by the carrier of a right to change premiums; and (E) a statement that the outline is a summary of the policy issued or applied for and that the policy should be consulted to determine governing contractual provisions.

      (g) Notwithstanding the provisions of sections 38a-80, 38a-321 to 38a-324, inclusive, 38a-326, 38a-329, 38a-334 to 38a-336a, inclusive, 38a-338 to 38a-358, inclusive, 38a-470 to 38a-472, inclusive, 38a-475, 38a-480 to 38a-503, inclusive, 38a-507, 38a-514, 38a-519, 38a-523, 38a-531, 38a-577 to 38a-590, inclusive, and 38a-802 to 38a-810, inclusive, if a carrier elects to use a simplified application form, with or without any questions as to the applicant's health at the time of application, but without any questions concerning the insured's health history or medical treatment history, the policy shall cover loss developing after twelve months from any preexisting condition not specifically excluded from coverage by the terms of the policy and, except as so provided, the policy shall not include wording that would permit a defense based upon preexisting conditions.

      (h) Regulations promulgated pursuant to this section shall specify an effective date applicable to policy and benefit riders delivered or issued for delivery in this state on and after such effective date which shall not be less than one hundred eighty days after the date of adoption or promulgation.

      (P.A. 75-616, S. 8, 12; P.A. 76-399, S. 4, 5; P.A. 90-200, S. 2; 90-243, S. 155; P.A. 93-297, S. 22, 23, 29.)

      History: P.A. 76-399 clarified prohibition of specific disease policies in Subsec. (c) to specify "riders and benefits" and "whether issued on a group or individual basis"; P.A. 90-200 amended Subsec. (c) to allow the issuance of specified disease policies for accelerated benefits of life insurance policies provided the commissioner adopts regulations re minimum standards for issuance; P.A. 90-243 substituted "health insurance policies" for "accident and sickness contracts" and deleted the reference to "contracts"; Sec. 38-378 transferred to Sec. 38a-505 in 1991; P.A. 93-297 added references to Sec. 38a-336a in Subsecs. (a) and (g), effective January 1, 1994, and applicable to acts or omissions occurring on or after said date.

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      Sec. 38a-506. (Formerly Sec. 38-173). Penalty. Any insurer, hospital or medical service corporation, health care center or fraternal benefit society, or any officer or agent thereof, delivering or issuing for delivery to any person in this state any policy in violation of any of the provisions of sections 38a-481 to 38a-488, inclusive, shall be fined not more than five hundred dollars for each offense, and the commissioner may revoke the license of any foreign or alien insurer, or any agent thereof, violating any of said provisions.

      (1949 Rev., S. 6189; 1951, S. 2843d; P.A. 90-243, S. 95.)

      History: P.A. 90-243 applied provisions to hospital or medical service corporations, health care centers, and fraternal benefit societies and substituted "foreign" for "nonresident" and "alien" for "foreign" insurance companies; Sec. 38-173 transferred to Sec. 38a-506 in 1991.

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      Sec. 38a-507. Coverage for services performed by chiropractors. Every individual health insurance policy delivered, issued for delivery or renewed in this state on or after October 1, 1989, shall provide coverage for services rendered by a chiropractor licensed under chapter 372 to the same extent coverage is provided for services rendered by a physician, if such chiropractic services (1) treat a condition covered under such policy and (2) are within those services a chiropractor is licensed to perform.

      (P.A. 89-112; P.A. 90-243, S. 176.)

      History: P.A. 90-243 substituted "health insurance policy" for "group hospital", "medical expense insurance policy" and "individual or group hospital or medical service plan" and deleted references to "contract".

      See Sec. 38a-534 for similar provisions re group policies.

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      Sec. 38a-508. Coverage for adopted children. (a) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state shall provide coverage for a child legally placed for adoption with the insured or subscriber who is an adoptive parent or a prospective adoptive parent, even though the adoption has not been finalized, provided the child lives in the household of such insured or subscriber and the child is dependent upon such person for support and maintenance.

      (b) Coverage for such child legally placed for adoption shall consist of coverage for injury and sickness including necessary care and treatment of medically diagnosed congenital defects and birth abnormalities within the limits of the policy.

      (c) If payment of a specific premium or subscription fee is required to provide coverage for a child legally placed for adoption with the insured or subscriber who is an adoptive parent or a prospective adoptive parent, the policy or contract may require that notification of acceptance of such child and payment of the required premium or fees be furnished to the insurer, hospital or medical service corporation or health care center within thirty-one days after the acceptance of such child in order to continue coverage beyond such thirty-one-day period, provided failure to furnish such notice or pay such premium or fees shall not prejudice any claim originating within such thirty-one-day period.

      (d) Such policy (1) shall cover such child legally placed for adoption on the same basis as other dependents, and (2) may not contain any provision concerning preexisting conditions, insurability, eligibility or health underwriting approval for a child legally placed for adoption, except that an insurer, hospital or medical service corporation or health care center may require health underwriting for a child legally placed for adoption if a required premium or subscription fee and completed application materials are not provided to the insurer, hospital or medical service corporation or health care center before the expiration of the thirty-one-day period following the date the child was legally placed for adoption.

      (P.A. 91-97, S. 1; P.A. 02-96, S. 1; P.A. 03-70, S. 1.)

      History: P.A. 02-96 amended Subsec. (a) to substitute "each" for "every" and "amended, renewed or continued in this state" for "amended or renewed in this state on or after October 1, 1991," and added Subsec. (d) re coverage and prohibited provisions; P.A. 03-70 amended Subsec. (d) to add exception re health underwriting if required premium or subscription fee and completed application materials are not provided before expiration of thirty-one-day period.

      See Sec. 38a-549 for similar provisions re group policies.

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      Secs. 38a-509 to 38a-511. Reserved for future use.

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PART III
GROUP HEALTH INSURANCE

      Sec. 38a-512. Applicability of statutes to certain major medical expense policies. Any policy providing major medical expense coverage which is written to complement underlying hospital, medical and surgical expense coverage, unless otherwise specifically provided, shall not be required to include the benefits required in the underlying hospital, medical and surgical expense coverage. The provisions of sections 38a-513, 38a-529, 38a-532, 38a-545 and 38a-547 shall not apply to any subscriber contract issued by a health care center.

      (P.A. 90-243, S. 96; P.A. 03-199, S. 6.)

      History: P.A. 03-199 deleted provision re inapplicability of Sec. 38a-546 to subscriber contracts issued by a health care center.

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      Sec. 38a-513. Approval of group health insurance policy forms. Age, gender, previous claim or medical history rating prohibited. Exceptions. Optional life insurance riders. (a) No group health insurance policy, as defined by the commissioner, or certificate shall be issued or delivered in this state unless a copy of the form thereof has been submitted to and approved by the commissioner under such reasonable regulations as he makes concerning the provisions in such contracts and their submission to and approval by him. The commissioner shall adopt regulations in accordance with the provisions of chapter 54, establishing a procedure for review of such policies and certificates. If the commissioner issues an order disapproving the use of such form, the provisions of section 38a-19 shall apply to such order.

      (b) No insurance company, fraternal benefit society, hospital service corporation, medical service corporation, health care center or 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.

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

      (P.A. 90-243, S. 97; P.A. 93-390, S. 7, 8; P.A. 96-51, S. 3.)

      History: P.A. 93-390 added Subsec. (b) prohibiting the incorporation of factors for age, gender, previous claim or medical condition history, into the insurer's rate schedule, effective January 1, 1994; P.A. 96-51 added Subsec. (c) to permit optional life insurance riders.

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      Sec. 38a-513a. Time limits for coverage determinations. Notice requirements. Except as otherwise provided in this title, each insurer, health care center, hospital and medical service corporation or other entity delivering, issuing for delivery, renewing or amending any group health insurance policy in this state on or after January 1, 2000, providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 shall complete any coverage determination with respect to such policy and notify the insured or the insured's health care provider of its decision not later than forty-five days after a request for such determination is received by the insurer, health care center, hospital and medical service corporation or other entity. In the case of a denial of coverage, such entity shall notify the insured and the insured's health care provider of the reasons for such denial.

      (P.A. 99-284, S. 13.)

      See Sec. 38a-483b for similar provisions re individual policies.

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      Sec. 38a-513b. Coverage and notice re experimental treatments. Appeals. (a) Each group health insurance policy delivered, issued for delivery, renewed, amended or continued in this state on or after January 1, 2000, shall define the extent to which it provides coverage for experimental treatments.

      (b) No such health insurance policy may deny a procedure, treatment or the use of any drug as experimental if such procedure, treatment or drug, for the illness or condition being treated, or for the diagnosis for which it is being prescribed, has successfully completed a phase III clinical trial of the federal Food and Drug Administration.

      (c) Any person who has been diagnosed with a condition that creates a life expectancy in that person of less than two years and who has been denied an otherwise covered procedure, treatment or drug on the grounds that it is experimental may request an expedited appeal as provided in section 38a-226c and may appeal a denial thereof to the Insurance Commissioner in accordance with the procedures established in section 38a-478n.

      (d) For the purposes of conducting an appeal pursuant to section 38a-478n on the grounds that an otherwise covered procedure, treatment or drug is experimental, the basis of such an appeal shall be the medical efficacy of such procedure, treatment or drug. The entity conducting the review may consider whether the procedure, treatment or drug (1) has been approved by the National Institute of Health or the American Medical Association, (2) is listed in the United States Pharmacopoeia Drug Information Guide for Health Care Professionals (USP-DI), the American Medical Association Drug Evaluations (AMA-DE), or the American Society of Hospital Pharmacists' American Hospital Formulary Service Drug Information (AHFS-DI), or (3) is currently in a phase III clinical trial of the federal Food and Drug Administration.

      (P.A. 99-284, S. 16, 60.)

      History: P.A. 99-284 effective January 1, 2000.

      See Sec. 38a-483c for similar provisions re individual policies.

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      Sec. 38a-514. (Formerly Sec. 38-174d). Mandatory coverage for the diagnosis and treatment of mental or nervous conditions. Exceptions. Benefits payable re type of provider or facility. State's claim against proceeds. (a) Except as provided in subsection (j) of this section, each group health insurance policy, providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469, delivered, issued for delivery, renewed, amended or continued in this state on or after January 1, 2000, shall provide benefits for the diagnosis and treatment of mental or nervous conditions. For the purposes of this section, "mental or nervous conditions" means mental disorders, as defined in the most recent edition of the American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Disorders". "Mental or nervous conditions" does not include (1) mental retardation, (2) learning disorders, (3) motor skills disorders, (4) communication disorders, (5) caffeine-related disorders, (6) relational problems, and (7) additional conditions that may be a focus of clinical attention, that are not otherwise defined as mental disorders in the most recent edition of the American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Disorders".

      (b) No such group policy shall establish any terms, conditions or benefits that place a greater financial burden on an insured for access to diagnosis or treatment of mental or nervous conditions than for diagnosis or treatment of medical, surgical or other physical health conditions.

      (c) In the case of benefits payable for the services of a licensed physician, such benefits shall be payable for the same services when such services are lawfully rendered by a psychologist licensed under the provisions of chapter 383 or by such a licensed psychologist in a licensed hospital or clinic.

      (d) In the case of benefits payable for the services of a licensed physician or psychologist, such benefits shall be payable for the same services when such services are rendered by:

      (1) A clinical social worker who is licensed under the provisions of chapter 383b and who has passed the clinical examination of the American Association of State Social Work Boards and has completed at least two thousand hours of post-master's social work experience in a nonprofit agency qualifying as a tax-exempt organization under Section 501(c) of the Internal Revenue Code of 1986 or any subsequent corresponding internal revenue code of the United States, as from time to time amended, in a municipal, state or federal agency or in an institution licensed by the Department of Public Health under section 19a-490;

      (2) A social worker who was certified as an independent social worker under the provisions of chapter 383b prior to October 1, 1990;

      (3) A licensed marital and family therapist who has completed at least two thousand hours of post-master's marriage and family therapy work experience in a nonprofit agency qualifying as a tax-exempt organization under Section 501(c) of the Internal Revenue Code of 1986 or any subsequent corresponding internal revenue code of the United States, as from time to time amended, in a municipal, state or federal agency or in an institution licensed by the Department of Public Health under section 19a-490;

      (4) A marital and family therapist who was certified under the provisions of chapter 383a prior to October 1, 1992;

      (5) A licensed alcohol and drug counselor, as defined in section 20-74s, or a certified alcohol and drug counselor, as defined in section 20-74s; or

      (6) A licensed professional counselor.

      (e) For purposes of this section, the term "covered expenses" means the usual, customary and reasonable charges for treatment deemed necessary under generally accepted medical standards, except that in the case of a managed care plan, as defined in section 38a-478, "covered expenses" means the payments agreed upon in the contract between a managed care organization, as defined in section 38a-478, and a provider, as defined in section 38a-478.

      (f) (1) In the case of benefits payable for the services of a licensed physician, such benefits shall be payable for (A) services rendered in a child guidance clinic or residential treatment facility by a person with a master's degree in social work or by a person with a master's degree in marriage and family therapy under the supervision of a psychiatrist, physician, licensed marital and family therapist or licensed clinical social worker who is eligible for reimbursement under subdivisions (1) to (4), inclusive, of subsection (d) of this section; (B) services rendered in a residential treatment facility by a licensed or certified alcohol and drug counselor who is eligible for reimbursement under subdivision (5) of subsection (d) of this section; or (C) services rendered in a residential treatment facility by a licensed professional counselor who is eligible for reimbursement under subdivision (6) of subsection (d) of this section.

      (2) In the case of benefits payable for the services of a licensed psychologist under subsection (d) of this section, such benefits shall be payable for (A) services rendered in a child guidance clinic or residential treatment facility by a person with a master's degree in social work or by a person with a master's degree in marriage and family therapy under the supervision of such licensed psychologist, licensed marital and family therapist or licensed clinical social worker who is eligible for reimbursement under subdivisions (1) to (4), inclusive, of subsection (d) of this section; (B) services rendered in a residential treatment facility by a licensed or certified alcohol and drug counselor who is eligible for reimbursement under subdivision (5) of subsection (d) of this section; or (C) services rendered in a residential treatment facility by a licensed professional counselor who is eligible for reimbursement under subdivision (6) of subsection (d) of this section.

      (g) In the case of benefits payable for the service of a licensed physician practicing as a psychiatrist or a licensed psychologist, under subsection (d) of this section, such benefits shall be payable for outpatient services rendered (1) in a nonprofit community mental health center, as defined by the Department of Mental Health and Addiction Services, in a nonprofit licensed adult psychiatric clinic operated by an accredited hospital or in a residential treatment facility; (2) under the supervision of a licensed physician practicing as a psychiatrist, a licensed psychologist, a licensed marital and family therapist, a licensed clinical social worker, a licensed or certified alcohol and drug counselor, or a licensed professional counselor who is eligible for reimbursement under subdivisions (1) to (6), inclusive, of subsection (d) of this section; and (3) within the scope of the license issued to the center or clinic by the Department of Public Health or to the residential treatment facility by the Department of Children and Families.

      (h) Except in the case of emergency services or in the case of services for which an individual has been referred by a physician affiliated with a health care center, nothing in this section shall be construed to require a health care center to provide benefits under this section through facilities that are not affiliated with the health care center.

      (i) In the case of any person admitted to a state institution or facility administered by the Department of Mental Health and Addiction Services, Department of Public Health, Department of Children and Families or the Department of Mental Retardation, the state shall have a lien upon the proceeds of any coverage available to such person or a legally liable relative of such person under the terms of this section, to the extent of the per capita cost of such person's care. Except in the case of emergency services the provisions of this subsection shall not apply to coverage provided under a managed care plan, as defined in section 38a-478.

      (j) A group health insurance policy may exclude the benefits required by this section if such benefits are included in a separate policy issued to the same group by an insurance company, health care center, hospital service corporation, medical service corporation or fraternal benefit society. Such separate policy, which shall include the benefits required by this section and the benefits required by section 38a-533, shall not be required to include any other benefits mandated by this title.

      (k) In the case of benefits based upon confinement in a residential treatment facility, such benefits shall be payable only in situations in which (A) the insured has a serious mental illness which substantially impairs the person's thought, perception of reality, emotional process, or judgment or grossly impairs behavior as manifested by recent disturbed behavior, (B) the insured has been confined in a hospital for such illness for a period of at least three days immediately preceding such confinement in a residential treatment facility, and (C) such illness would otherwise necessitate continued confinement in a hospital if such care and treatment were not available through a residential treatment center for children and adolescents.

      (l) The services rendered for which benefits are to be paid for confinement in a residential treatment facility must be based on an individual treatment plan. For purposes of this section, the term "individual treatment plan" means a treatment plan prescribed by a physician with specific attainable goals and objectives appropriate to both the patient and the treatment modality of the program.

      (1971, P.A. 238, S. 1; P.A. 74-34, S. 1, 2; P.A. 75-215, S. 1, 2; 75-286; P.A. 77-604, S. 24, 84; P.A. 79-614; P.A. 82-110; P.A. 83-157; P.A. 84-193, 84-455, S. 2; P.A. 87-275, S. 1; P.A. 89-86, S. 1; P.A. 90-108; 90-193; 90-243, S. 98; P.A. 92-117; P.A. 93-91, S. 1, 2; 93-381, S. 9, 39; P.A. 95-75; 95-116, S. 6; 95-257, S. 11, 12, 21, 58; 95-289, S. 10, 11; P.A. 96-180, S. 122, 166; P.A. 99-284, S. 28, 60; P.A. 00-135, S. 11, 21; P.A. 02-24, S. 7.)

      History: P.A. 74-34 clarified prohibition by rephrasing statement of applicability and defined "covered expenses"; P.A. 75-215 included renewals in applicability provision and deleted obsolete date reference, raised minimum confinement period from thirty to sixty days in Subsec. (a) and maximum dollar amount of major medical coverage from five hundred to one thousand dollars in Subsec. (b) and redefined "covered expenses" to include reference to usual and customary charges; P.A. 75-286 added Subsec. (c) re services of psychologists; P.A. 77-604 designated definition of "covered expenses" as Subsec. (d); P.A. 79-614 added Subsec. (e) re services of child guidance clinics; P.A. 82-110 inserted new Subsec. (b) re benefits for partial hospitalization sessions, relettering as necessary and added provisions re additional benefits in Subsec. (c), formerly (b); P.A. 83-157 added Subsec. (g) which outlines when benefits shall be payable for the outpatient services of a psychiatrist or psychologist; P.A. 84-193 required that medical benefits contracts issued by health care centers comply with the mental health coverage requirements of this section, except as limited in new Subsec. (h); P.A. 84-455 added Subsec. (i) creating state's lien upon insurance coverage available to persons receiving care or legally liable relatives; P.A. 87-275 amended Subsec. (c) to increase the maximum for outpatient benefits from one thousand to two thousand dollars; P.A. 89-86 added Subsec. (j) providing for exclusion of the benefits required by this section in a group contract if such benefits are included in a separate contract issued to the same group which also includes the benefits required by Sec. 38-262b; P.A. 90-108 amended Subsec. (a) to define "residential treatment facility", added references to "residential treatment facility" to require that mental health benefits must be offered in a setting other than a hospital, added new Subsecs. (l) and (m) specifying that for benefits in a residential treatment center to be payable, the insured must have a serious mental illness, must be hospitalized within a specific time period after confinement in the residential treatment facility and would have been hospitalized if not for the existence of a residential treatment center and that treatment must be based on an individual plan tailored to the patient; P.A. 90-193 inserted new Subsec. (e) re services of certified independent social workers, relettering the remaining Subsecs. and adding references to certified independent social workers in Subsecs. (g) and (h); P.A. 90-243 added a reference to "group health insurance policy" and substituted "policy" for "contract" where occurring; Sec. 38-174d transferred to Sec. 38a-514 in 1991; P.A. 92-117 amended Subsec. (e) to make its provisions apply to the services of a Connecticut certified marriage and family therapist certified prior to October 1, 1992, amended Subsec. (g) to make provisions applicable to the services rendered by a Connecticut certified marriage and family therapist and made technical corrections for statutory consistency throughout section; P.A. 93-91 substituted commissioner and department of children and families for commissioner and department of children and youth services, effective July 1, 1993; P.A. 93-381 replaced department of health services with department of public health and addiction services, effective July 1, 1993; P.A. 95-75 amended Subsec. (g) to authorize payment of benefits for services rendered by a person with a master's degree in marriage and family therapy under the supervision of a psychiatrist, physician, Connecticut certified marriage and family therapist or a certified independent social worker; P.A. 95-116 replaced references to certified independent social workers with references to licensed clinical social workers; P.A. 95-257 replaced Commissioner and Department of Public Health and Addiction Services with Commissioner and Department of Public Health and replaced Commissioner and Department of Mental Health with Commissioner and Department of Mental Health and Addiction Services, effective July 1, 1995; P.A. 95-289 made technical changes to Subsecs. (e), (g) and (h) concerning changing marital and family therapists from "certified" to "licensed"; P.A. 96-180 amended Subdiv. (4) of Subsec. (e) to substitute "marital" for "marriage" in reference to "marital and family therapist", effective June 3, 1996; P.A. 99-284 rewrote introductory language and designated it as Subsec. (a), added reference to Subdivs. (1), (2), (4), (11) and (12) of section 38a-469, and added coverage for "mental or nervous conditions" and defined term, deleted provisions of Subsecs. (a), (b) and (c), inserted new Subsec. (b) re requirement that no policy place a greater financial burden on an insured for access to diagnosis or treatment of mental or nervous conditions than for other conditions, redesignated former Subsecs. (d) and (e) as (c) and (d), respectively, and added Subdiv. (d)(5) re alcohol and drug counselors, redesignated former Subsec. (f) as (e) and added exception for managed care plans, redesignated former Subsecs. (g) and (h) as (f) and (g), respectively, and added Subdiv. (f)(3) and amended Subdiv. (h)(2) re alcohol and drug counselors, redesignated Subsecs. (i) and (j) as (h) and (i), respectively, and amended Subsec. (i) to add exception re coverage provided under a managed care plan, redesignated former Subsecs. (k), (l) and (m) as (j), (k) and (l), respectively, and made technical changes, effective January 1, 2000; P.A. 00-135 reorganized section and added provisions re licensed professional counselors, effective May 26, 2000; P.A. 02-24 deleted "the" re "post-master's social work experience" in Subsec. (d)(1) and (3).

      See Sec. 38a-538 re conversion and extension rights of group members and re liability of group employers.

      See Sec. 38a-488a for similar provisions re individual policies.

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      Sec. 38a-514a. Biologically-based mental illness. Coverage required. Section 38a-514a is repealed, effective January 1, 2000.

      (P.A. 97-99, S. 27; June 18 Sp. Sess. P.A. 97-8, S. 62, 88; P.A. 99-284, S. 59, 60.)

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      Sec. 38a-515. Continuation of coverage of mentally retarded or physically handicapped dependent children. (a) Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (11) and (12) of section 38a-469 delivered or issued for delivery in this state more than one hundred twenty days after July 1, 1971, which provides that coverage of a dependent child of an employee or other member of the covered group shall terminate upon attainment of the limiting age for dependent children specified in the policy shall also provide in substance that attainment of the limiting age shall not operate to terminate the coverage of the child if at such date the child is and continues thereafter to be both (1) incapable of self-sustaining employment by reason of mental or physical handicap, as certified by the child's physician on a form provided by the insurer, hospital or medical service corporation, or health care center and (2) chiefly dependent upon such employee or member for support and maintenance.

      (b) Proof of the incapacity and dependency shall be furnished to the insurer, hospital or medical service plan corporation or health care center by the employee or member within thirty-one days of the child's attainment of the limiting age. The insurer, corporation or center may at any time require proof of the child's continuing incapacity and dependency. After a period of two years has elapsed following the child's attainment of the limiting age the insurer, corporation or center may require periodic proof of the child's continuing incapacity and dependency but in no case more frequently than once every year.

      (P.A. 90-243, S. 99.)

      See Sec. 38a-489 for similar provisions re individual policies.

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      Sec. 38a-516. Coverage for newborn infants in health insurance policies. Notice. Application. (a) Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (11) and (12) of section 38a-469 for a family member of the insured or subscriber shall also provide as to such family members' coverage, that the health insurance benefits applicable for children shall be payable with respect to a newly born child of the insured or subscriber from the moment of birth.

      (b) Coverage for such newly born child shall consist of coverage for injury and sickness including necessary care and treatment of medically diagnosed congenital defects and birth abnormalities within the limits of the policy.

      (c) If payment of a specific premium fee is required to provide coverage for a child, the policy may require that notification of birth of such newly born child and payment of the required premium or fees shall be furnished to the insurer, hospital or medical service corporation or health care center within thirty-one days after the date of birth in order to continue coverage beyond such thirty-one-day period, provided failure to furnish such notice or pay such premium shall not prejudice any claim originating within such thirty-one-day period.

      (d) The provisions of this section shall apply with respect to health insurance policies delivered or issued for delivery in this state on or after October 1, 1974, and to any health insurance policies which are thereafter amended to substantially alter or change benefits or coverages.

      (P.A. 90-243, S. 100.)

      See Sec. 38a-490 for similar provisions re individual policies.

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      Sec. 38a-516a. Coverage for birth-to-three program. Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery or renewed in this state on or after July 1, 1996, shall provide coverage for medically necessary early intervention services provided as part of an individualized family service plan pursuant to section 17a-248e. Such policy shall provide (1) coverage for such services provided by qualified personnel, as defined in section 17a-248, for a child from birth until the child's third birthday, and (2) a maximum benefit of three thousand two hundred dollars per child per year and an aggregate benefit of nine thousand six hundred dollars per child over the total three-year period. No payment made under this section shall be applied by the insurer, health care center or plan administrator against any maximum lifetime or annual limits specified in the policy or health benefits plan.

      (P.A. 96-185, S. 7, 16; June 30 Sp. Sess. P.A. 03-3, S. 8.)

      History: P.A. 96-185 effective July 1, 1996; June 30 Sp. Sess. P.A. 03-3 deleted provision re coverage for at least five thousand dollars annually, added Subdivs. (1) and (2) re coverage and benefits to be provided by policy and made technical changes, effective August 20, 2003.

      See Sec. 38a-490a for similar provisions re individual policies.

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      Sec. 38a-516b. Coverage for hearing aids for children twelve and under. Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state on or after October 1, 2001, shall provide coverage for hearing aids for children twelve years of age or younger. Such hearing aids shall be considered durable medical equipment under the policy and the policy may limit the hearing aid benefit to one thousand dollars within a twenty-four-month period.

      (P.A. 01-171, S. 16.)

      See Sec. 38a-490b for similar provisions re individual policies.

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      Sec. 38a-516c. Coverage for craniofacial disorders. Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state on or after October 1, 2003, shall provide coverage for medically necessary orthodontic processes and appliances for the treatment of craniofacial disorders for individuals eighteen years of age or younger if such processes and appliances are prescribed by a craniofacial team recognized by the American Cleft Palate-Craniofacial Association, except that no coverage shall be required for cosmetic surgery.

      (P.A. 03-37, S. 2.)

      See Sec. 38a-490c for similar provisions re individual policies.

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      Sec. 38a-517. Coverage for services performed by dentist in certain instances. Whenever the term "physician" or "doctor" is used in any group health insurance policy delivered, issued for delivery or renewed in this state on or after October 1, 1975, it shall be deemed to include persons licensed, under the provisions of chapter 379, to engage in the practice of dentistry or dental medicine, when benefits under such policy for care, treatment or services rendered or procedures performed by such person would be payable if rendered or performed by a person licensed under chapter 370.

      (P.A. 90-243, S. 101.)

      See Sec. 38a-491 for similar provisions re individual policies.

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      Sec. 38a-517a. Coverage for in-patient, outpatient or one-day dental services in certain instances. (a) Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed or continued in this state on or after January 1, 2000, shall provide coverage for general anesthesia, nursing and related hospital services provided in conjunction with in-patient, outpatient or one-day dental services if the following conditions are met:

      (1) The anesthesia, nursing and related hospital services are deemed medically necessary by the treating dentist or oral surgeon and the patient's primary care physician in accordance with the health insurance policy's requirements for prior authorization of services; and

      (2) The patient is either (A) determined by a licensed dentist, in conjunction with a licensed physician who specializes in primary care, to have a dental condition of significant dental complexity that it requires certain dental procedures to be performed in a hospital, or (B) a person who has a developmental disability, as determined by a licensed physician who specializes in primary care, that places the person at serious risk.

      (b) The expense of such anesthesia, nursing and related hospital services shall be deemed a medical expense under such health insurance policy and shall not be subject to any limits on dental benefits under such policy.

      (P.A. 99-284, S. 41, 60; P.A. 00-135, S. 14, 21; P.A. 03-58, S. 2.)

      History: P.A. 99-284 effective January 1, 2000; P.A. 00-135 added outpatient or one-day dental services, effective May 26, 2000; P.A. 03-58 divided existing provisions into Subsecs. (a) and (b) and deleted "a child under the age of four who is" from Subsec. (a)(2)(A).

      See Sec. 38a-491a for similar provisions re individual policies.

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      Sec. 38a-517b. Assignment of benefits to a dentist or oral surgeon. No insurer, health care center, hospital and medical service corporation or other entity delivering, issuing for delivery, renewing, continuing or amending any group health insurance policy in this state on or after July 1, 2000, providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469, and no dental services plan offering or administering dental services may refuse to accept or make reimbursement pursuant to an assignment of benefits made to a dentist or oral surgeon by an insured, subscriber or enrollee, provided (1) the dentist or oral surgeon charges the insured, subscriber or enrollee no more for services than the dentist or surgeon charges uninsured patients for the same services, and (2) the dentist or oral surgeon allows the insurer, health care center, corporation or entity to review the records related to the insured, subscriber or enrollee during regular business hours. The insurer, health care center, corporation or entity shall give the dentist or oral surgeon at least forty-eight hours' notice prior to such review. As used in this section, "assignment of benefits" means the transfer of dental care coverage reimbursement benefits or other rights under an insurance policy, subscription contract or dental services plan by an insured, subscriber or enrollee to a dentist or oral surgeon.

      (P.A. 00-33, S. 2, 3.)

      History: P.A. 00-33 effective July 1, 2000.

      See Sec. 38a-491b for similar provisions re individual policies.

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      Sec. 38a-518. Coverage for accidental ingestion or consumption of controlled drugs. Benefits prescribed. No group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6) and (11) of section 38a-469 shall be delivered, issued for delivery or renewed in this state, or amended to substantially alter or change benefits or coverage, on or after July 1, 1975, unless persons covered under such policy will be eligible for benefits for expenses of emergency medical care arising from accidental ingestion or consumption of a controlled drug, as defined by subdivision (8) of section 21a-240, which are at least equal to the following minimum requirements: (1) In the case of benefits based upon confinement as an inpatient in a hospital, whether or not operated by the state, the period of confinement for which benefits shall be payable shall be at least thirty days in any calendar year. (2) For covered expenses incurred by the insured while other than an inpatient in a hospital, benefits shall be available for such expenses during any calendar year up to a maximum of five hundred dollars. For purposes of this section, the term "covered expenses" means the reasonable charges for treatment deemed necessary under generally accepted medical standards.

      (P.A. 90-243, S. 102.)

      See Sec. 38a-492 for similar provisions re individual policies.

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      Sec. 38a-518a. Mandatory coverage for hypodermic needles and syringes. Every group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469, delivered, issued for delivery or renewed in this state on or after July 1, 1992, shall provide coverage for hypodermic needles or syringes prescribed by a prescribing practitioner, as defined in subdivision (22) of section 20-571, for the purpose of administering medications for medical conditions, provided such medications are covered under the policy. Such benefits shall be subject to any policy provisions that apply to other services covered by such policy.

      (P.A. 92-185, S. 5, 6; P.A. 95-264, S. 63.)

      History: P.A. 95-269 changed "licensed" practitioner to "prescribing" practitioner and referenced the definition section (Revisor's note: The reference to "prescribing practitioner, as defined in subdivision (21) of ..." was changed editorially by the Revisors to "prescribing practitioner, as defined in subdivision (22) of ...").

      See Sec. 38a-492a for similar provisions re individual policies.

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      Sec. 38a-518b. Coverage for off-label drug prescriptions. (a) Each group health insurance policy delivered, issued for delivery or renewed in this state on or after October 1, 1994, which provides coverage for prescribed drugs approved by the federal Food and Drug Administration for treatment of certain types of cancer shall not exclude coverage of any such drug on the basis that such drug has been prescribed for the treatment of a type of cancer for which the drug has not been approved by the federal Food and Drug Administration, provided the drug is recognized for treatment of the specific type of cancer for which the drug has been prescribed in one of the following established reference compendia: (1) The U.S. Pharmacopoeia Drug Information Guide for the Health Care Professional (USP DI); (2) The American Medical Association's Drug Evaluations (AMA DE); or (3) The American Society of Hospital Pharmacists' American Hospital Formulary Service Drug Information (AHFS-DI).

      (b) Nothing in subsection (a) of this section shall be construed to require coverage for any experimental or investigational drugs or any drug which the federal Food and Drug Administration has determined to be contraindicated for treatment of the specific type of cancer for which the drug has been prescribed.

      (c) Nothing in this section shall be construed to create, impair, limit or modify authority to provide reimbursement for drugs used in the treatment of any other disease or condition.

      (P.A. 94-49, S. 1.)

      See Sec. 38a-492b for similar provisions re individual policies.

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      Sec. 38a-518c. Coverage for low protein modified food products, amino acid modified preparations and specialized formulas. (a) For purposes of this section:

      (1) "Inherited metabolic disease" includes (A) a disease for which newborn screening is required under section 19a-55; and (B) cystic fibrosis.

      (2) "Low protein modified food product" means a product formulated to have less than one gram of protein per serving and intended for the dietary treatment of an inherited metabolic disease under the direction of a physician.

      (3) "Amino acid modified preparation" means a product intended for the dietary treatment of an inherited metabolic disease under the direction of a physician.

      (4) "Specialized formula" means a nutritional formula for children up to age eight that is exempt from the general requirements for nutritional labeling under the statutory and regulatory guidelines of the federal Food and Drug Administration and is intended for use solely under medical supervision in the dietary management of specific diseases.

      (b) Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (11) and (12) of section 38a-469 delivered, issued for delivery or renewed in this state on or after October 1, 1997, shall provide coverage for amino acid modified preparations and low protein modified food products for the treatment of inherited metabolic diseases if the amino acid modified preparations or low protein modified food products are prescribed for the therapeutic treatment of inherited metabolic diseases and are administered under the direction of a physician.

      (c) Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (11) and (12) of section 38a-469 delivered, issued for delivery or renewed in this state on or after October 1, 2001, shall provide coverage for specialized formulas when such specialized formulas are medically necessary for the treatment of a disease or condition and are administered under the direction of a physician.

      (d) Such policy shall provide coverage for such preparations, food products and formulas on the same basis as outpatient prescription drugs.

      (P.A. 97-167, S. 2; P.A. 01-101, S. 2; P.A. 04-173, S. 2.)

      History: P.A. 01-101 defined, in new Subsec. (a)(4), and added coverage, in new Subsec. (c), for specialized formula; P.A. 04-173 amended Subsec. (a)(1) and (4) to redefine "inherited metabolic disease" to include cystic fibrosis, and redefine "specialized formula" to include formula for children up to age eight, instead of age three, and added Subsec. (d) to require coverage on the same basis as for outpatient prescription drugs.

      See Sec. 38a-492c for similar provisions re individual policies.

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      Sec. 38a-518d. Mandatory coverage for diabetes testing and treatment. (a) Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery or renewed in this state on or after October 1, 1997, shall provide coverage for laboratory and diagnostic tests for all types of diabetes.

      (b) Notwithstanding the provisions of section 38a-518a, each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery or renewed in this state on or after October 1, 1997, shall provide medically necessary coverage for the treatment of insulin-dependent diabetes, insulin-using diabetes, gestational diabetes and non-insulin-using diabetes. Such coverage shall include medically necessary equipment, in accordance with the insured person's treatment plan, drugs and supplies prescribed by a prescribing practitioner, as defined in section 20-571.

      (P.A. 97-268, S. 5.)

      See Sec. 38a-492d for similar provisions re individual policies.

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      Sec. 38a-518e. Mandatory coverage for diabetes outpatient self-management training. (a) Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed or continued in this state on or after January 1, 2000, shall provide coverage for outpatient self-management training for the treatment of insulin-dependent diabetes, insulin-using diabetes, gestational diabetes and non-insulin-using diabetes if the training is prescribed by a licensed health care professional who has appropriate state licensing authority to prescribe such training. As used in this section, "outpatient self-management training" includes, but is not limited to, education and medical nutrition therapy. Diabetes self-management training shall be provided by a certified, registered or licensed health care professional trained in the care and management of diabetes and authorized to provide such care within the scope of the professional's practice.

      (b) Benefits shall cover: (1) Initial training visits provided to an individual after the individual is initially diagnosed with diabetes that is medically necessary for the care and management of diabetes, including, but not limited to, counseling in nutrition and the proper use of equipment and supplies for the treatment of diabetes, totaling a maximum of ten hours; (2) training and education that is medically necessary as a result of a subsequent diagnosis by a physician of a significant change in the individual's symptoms or condition which requires modification of the individual's program of self-management of diabetes, totaling a maximum of four hours; and (3) training and education that is medically necessary because of the development of new techniques and treatment for diabetes totaling a maximum of four hours.

      (c) Benefits provided pursuant to this section shall be subject to the same terms and conditions applicable to all other benefits under such policies.

      (P.A. 99-284, S. 44, 60.)

      History: P.A. 99-284 effective January 1, 2000.

      See Sec. 38a-492e for similar provisions re individual policies.

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      Sec. 38a-518f. Mandatory coverage for certain prescription drugs removed from formulary. Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed or continued in this state on or after January 1, 2000, that provides coverage for outpatient prescription drugs shall not deny coverage for an insured for any drug that the insurer removes from its list of covered drugs, or otherwise ceases to provide coverage for, if (1) the insured was using the drug for the treatment of a chronic illness prior to the removal or cessation of coverage, (2) the insured was covered under the policy for the drug prior to the removal or cessation of coverage, and (3) the insured's attending health care provider states in writing, after the removal or cessation of coverage, that the drug is medically necessary and lists the reasons why the drug is more medically beneficial than the drugs on the list of covered drugs. Such benefits shall be subject to the same terms and conditions applicable to all other benefits under such policies.

      (P.A. 99-284, S. 38, 60.)

      History: P.A. 99-284 effective January 1, 2000.

      See Sec. 38a-492f for similar provisions re individual policies.

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