You asked for a comparison of overlapping federal and state health insurance mandates.

Connecticut insurance laws overlap and, in certain circumstances, expand upon federal laws regarding (1) adopted children, (2) coverage continuation, (3) guaranteed availability for small employers, (4) guaranteed plan renewal, (5) health status non-discrimination, (6) mastectomy reconstructive surgery, (7) mental health parity, (8) newborn and maternity hospital stay, (9) pediatric vaccines, (10) pre-existing conditions, and (11) pregnancy non-discrimination.

Federal laws apply to employee benefit plans, whether insured or self-insured. State laws apply to insured plans. In some instances, federal law sets a floor, allowing the States to require additional coverage. Some federal laws apply only to group plans, but often state law imposes the requirement on individual plans as well.

Table 1 provides the statutory citations for the identified overlapping federal and state laws. Table 2 gives the applicability of the federal and state laws (e. g. , applicable to plans issued to groups or individuals).

Table 1: Overlapping Federal and State Insurance Laws – Statutory Citations

Table 2: Applicability of Federal and State Insurance Laws

A group health plan providing coverage for dependent children of plan participants or beneficiaries must provide coverage to dependent children placed with the participants or beneficiaries for adoption under the same terms and conditions applying to dependent children who are the participants’ or beneficiaries’ natural children, regardless of whether the adoption has become final. Being placed for adoption means the assumption and retention by a person with a legal obligation to support the child in anticipation of the child’s adoption.

A group health plan is prohibited from restricting coverage of any dependent child adopted by or placed for adoption with a plan participant or beneficiary solely on the basis of the child’s pre-existing condition.

A group health plan must provide a special enrollment period for dependents, including dependent children adopted or placed for adoption. The enrollment period must be at least 30 days and begin on the later of (1) the date dependent coverage is made available or (2) the date of the adoption or placement for adoption. If the child is not enrolled within the special enrollment period, he will be considered a late enrollee at any other point of enrollment. Under federal law, a late enrollee (one who does not enroll during the plan’s open enrollment period or a special enrollment period) is subject to an extended pre-existing condition limitation period. If the child is enrolled within the first 30 days of the special enrollment period, coverage is effective on the date of the adoption or placement for adoption.

An individual or group health plan must provide coverage for a child legally placed for adoption with a plan participant or subscriber on the same basis as other dependents. The plan is prohibited from including provisions regarding pre-existing conditions, insurability, eligibility, or health underwriting approval. The participant or subscriber must enroll the child in the plan within 31 days from the adoption or placement for adoption. An insurer or HMO may require notification of the placement or adoption and payment of premium (if required) within the 31-day enrollment period to extend coverage beyond the first 31 days. If the child is not enrolled during the 31-day enrollment period, the insurer may require health underwriting of the child (CGS §§ 38a-508 and 549). However, this provision appears to conflict with federal HIPAA, which prohibits health underwriting for group health plan enrollees (including late enrollees).

The plan must cover injury and sickness, including necessary care and treatment of medically-diagnosed congenital defects and birth abnormalities within policy limits (CGS §§ 38a-508(b) and 549(b)). (This provision mirrors the State’s newborn infant coverage requirement – CGS §§ 38a-490 and 38a-516 --and, thus, is another way of saying adopted children must be covered on the same basis as other dependent children. )

The Consolidated Omnibus Budget Reconciliation Act (COBRA) gives employees and their families who lose their health benefits the right to choose to continue group health benefits provided by their group health plan for limited periods of time under certain circumstances such as voluntary or involuntary job loss, reduction in the hours worked, transition between jobs, death, divorce, and other life events. Qualified individuals may be required to pay the entire premium for coverage up to 102% of the group plan cost.

COBRA applies to group health plans sponsored by employers with 20 or more employees in the prior year. To be eligible for COBRA continuation, one must be a qualified beneficiary, which is an individual covered by a group health plan on the day before a qualifying event who is either an employee, the employee's spouse, or an employee's dependent child.   In certain cases, a retired employee, the retired employee's spouse, and the retired employee's dependent children may be qualified beneficiaries.   In addition, any child born to or placed for adoption with a covered employee during the period of COBRA coverage is considered a qualified beneficiary.

“Qualifying events” are certain events that would cause an individual to lose health coverage.   The type of qualifying event will determine who the qualified beneficiaries are and the amount of time that a plan must offer the health coverage to them under COBRA. Qualifying events for employees include voluntary or involuntary termination of employment for reasons other than gross misconduct and a reduction in the number of hours of employment. Qualifying events for spouses include (1) voluntary or involuntary termination of the covered employee's employment for any reason other than gross misconduct, (2) a reduction in the hours worked by the covered employee, (3) the covered employee’s becoming entitled to Medicare, (4) divorce or legal separation of the covered employee, and (5) death of the covered employee. Qualifying events for dependent children include (1) the loss of dependent child status under the plan rules, (2) voluntary or involuntary termination of the covered employee's employment for any reason other than gross misconduct, (3) a reduction in the hours worked by the covered employee, (4) the covered employee's becoming entitled to Medicare, (5) divorce or legal separation of the covered employee, and (6) death of the covered employee.

Qualified beneficiaries must be offered coverage identical to that available to similarly-situated beneficiaries who are not receiving COBRA coverage under the plan (generally, the same coverage that the qualified beneficiary had immediately before qualifying for continuation coverage).   A change in the benefits under the plan for the active employees will also apply to qualified beneficiaries.   Qualified beneficiaries must be allowed to make the same choices given to non-COBRA beneficiaries under the plan, such as during periods of open enrollment by the plan.

COBRA establishes required periods of coverage for continuation health benefits.   A plan, however, may provide longer periods of coverage beyond those required by COBRA.   COBRA beneficiaries generally are eligible for group coverage during a maximum of 18 months for qualifying events due to employment termination or reduction of hours of work.   Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage.

Disability can extend the 18 month period of continuation coverage for a qualifying event that is a termination of employment or reduction of hours.   To qualify for additional months of COBRA continuation coverage, the qualified beneficiary must have a ruling from the Social Security Administration that he became disabled within the first 60 days of COBRA continuation coverage and send the plan a copy of the Social Security ruling letter within 60 days of receipt, but before expiration of the 18-month period of coverage. If these requirements are met, the entire family qualifies for an additional 11 months of COBRA continuation coverage.   Plans can charge 150% of the premium cost for the extended period of coverage.

Continuation coverage begins on the date that coverage ended because of a qualifying event and ends at the end of the maximum coverage period.   It may end earlier if (1) premiums are not paid on a timely basis; (2) the employer ceases to maintain any group health plan; (3) after the COBRA election, coverage is obtained with another employer group health plan that does not contain any exclusion or limitation with respect to any pre-existing condition of the beneficiary; or (4) after the COBRA election, a beneficiary becomes entitled to Medicare benefits.   However, if other group health coverage or Medicare is obtained before COBRA election, COBRA coverage may not be discontinued, even if the other coverage continues after the COBRA election.

Some plans allow participants and beneficiaries to convert group health coverage to an individual policy.   If this option is generally available from the plan, a qualified beneficiary who pays for COBRA coverage must be given the option of converting to an individual policy at the end of the COBRA continuation coverage period.   The option must be given to enroll in a conversion health plan within 180 days before COBRA coverage ends.   The premium for a conversion policy may be more expensive than the premium of a group plan, and the conversion policy may provide a lower level of coverage.   The conversion option, however, is not available if the beneficiary ends COBRA coverage before reaching the end of the maximum period of COBRA coverage.

Connecticut law requires employers to comply with COBRA (CGS § 38a-538). It also requires each group health insurance policy, regardless of the number of insureds, to provide continuation benefits found in Section 38a-554(b) (CGS § 38a-546). Connecticut law requires group health insurance plans to provide the option to continue coverage under certain circumstances until a person is eligible for other group insurance.

Continuation of coverage is available to an employee and the employee’s covered dependents if the employee is laid-off, works reduced hours, takes a leave of absence, or terminates employment, other than as a result of gross misconduct. The employee’s spouse and dependent children are entitled to continue coverage under a group health plan if the employee dies, there is a divorce, court ordered annulment or legal separation, or the child loses dependent status through marriage or by reaching age 19 (age 23 if a full-time student at an accredited institution of higher learning).

Continuation of coverage generally extends for the periods of coverage set forth in COBRA. This means that coverage will extend for 18 months or 36 months depending on the qualifying event and possibly longer if the person is disabled. For group health insurance policies issued, renewed, or continued in Connecticut on or after October 1, 2003, an employee and such employee’s covered dependents are entitled to continue coverage until midnight of the day preceding the employee’s eligibility for Medicare if the employee’s reduced hours, leave of absence, or termination of employment results from his or her eligibility for Social Security income (PA 03-77).

Continuation of coverage may be subject to the requirement that the individual pay the premium for the coverage, up to 102% of the group rate.

Regardless of an individual’s eligibility for other group insurance, when a group health plan terminates, coverage for covered individuals who were totally disabled on the date the plan terminated will continue for 12 calendar months without payment of premium, provided a claim for coverage is submitted within one year of the plan termination. The individual receives coverage only for claims related to the disability.

If a person is not totally disabled on the date the plan terminates, state law does not require coverage continuation. Employees and their dependents will need to find coverage elsewhere (e. g. , enroll in a spouse’s plan, convert to an individual policy, or, if eligible, apply for coverage under a government program).

Each health insurer offering health insurance coverage in the small group market in a state must accept (1) every small employer in the state that applies for coverage and (2) every eligible person who applies for coverage under a small employer’s plan. If coverage is denied, the insurer is suspended from issuing coverage in the small group market for 180 days. A small employer is one that employs at least two but no more than 50 employees.

Connecticut law requires each insurer and HMO offering health insurance coverage in the small group market to comply with the federal requirements concerning guaranteed availability and disclosure of information for small employers (CGS § 38a-476a(c)). A small employer is one that employs no more than 50 employees, including a self-employed individual (CGS § 38a-564(4)).

If a health insurer offers health insurance in the individual or group market, the insurer must renew or continue in force the coverage at the option of the individual or group. It may only not renew or discontinue coverage for limited reasons, such as nonpayment of premiums or fraud.

Connecticut law requires each insurer and HMO offering health insurance coverage to comply with the federal requirements concerning guaranteed renewability of coverage (CGS § 38a-476a(a)).

Group health plans and health insurers offering group health insurance coverage are prohibited from establishing eligibility rules (including continued eligibility) for any person based on health status-related factors related to that person or his dependents. Factors include health status, medical condition (physical and mental), claims experience, receipt of health care, medical history, genetic information, evidence of insurability, and disability. The non-discrimination requirement does not (1) require a plan to provide particular benefits or (2) prohibit a plan from establishing benefit limitations or restrictions for similarly-situated individuals enrolled in the plan.

Group health plans and insurers are prohibited from requiring any person, as a condition of enrollment or continued enrollment under a plan, to pay a premium or contribution that is greater than that paid by a similarly-situated individual on the basis of any health status-related factor related to that person or his dependents. This does not prevent a plan or insurer from establishing premium discounts or rebates, or different copayments or deductibles, for a person who adheres to disease management and health promotion programs.

Connecticut law requires each insurer and HMO issuing group health plans to comply with the federal requirements concerning discrimination based on health status (CGS § 38a-476a(b)). In addition, it makes it an unfair and deceptive insurance practice for an insurer or HMO issuing individual or group health plans to (1) refuse to insure, (2) limit coverage, or (3) charge a different rate to an individual because of genetic information (CGS § 38a-816(19)).

A health plan and a health insurer issuing individual or group health insurance coverage that provides medical and surgical benefits for a mastectomy must provide, for a plan participant receiving such mastectomy benefits who elects breast reconstruction, coverage for (1) all stages of reconstruction of the breast on which the mastectomy was performed, (2) surgery and reconstruction of the other breast to produce a symmetrical appearance, and (3) prosthesis and physical complications, including lymphedemas. Coverage may be subject to deductibles and coinsurance consistent with those established for other benefits under the plan. Written notice of coverage must be provided to plan participants upon enrollment and annually thereafter.

Connecticut law requires each insurer and HMO issuing individual or group health insurance coverage to provide a yearly benefit of at least $ 500 for reconstructive surgery (CGS §§ 38a-504(a) and 38a-542(a)).

In addition, coverage must provide benefits for all the reasonable costs of reconstructive surgery on each breast on which a mastectomy was performed and reconstructive surgery on a non-diseased breast to produce a symmetrical appearance. Such benefits must be subject to the same terms and conditions applicable to other benefits under the plan (CGS §§ 38a-504(c) and 38a-542(c)).

Group health plans and insurers offering coverage for mental health services are prohibited from setting annual or lifetime dollar limits on mental health benefits that are lower than any such limits set on other medical and surgical benefits. If a plan does not impose annual or lifetime dollar limits on medical and surgical benefits, it is prohibited from imposing a dollar limit on mental health benefits. A plan is permitted to set terms and conditions (e. g. , copayment, limited number of visits or days of coverage) for the amount, duration, and scope of mental health benefits.

The federal law does not apply to (1) small employers (fewer than 51 employees) and (2) any group health plan whose costs increase one percent of more due to the mental health parity requirements that claims an exemption from the law.

Connecticut law requires each insurer and HMO issuing group health plans to comply with the federal requirements concerning parity of mental health benefits (CGS § 38a-476a(b)).

In addition, Connecticut law prohibits insurers and HMOs issuing individual or group health insurance coverage from establishing 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 (CGS §§ 38a-488a and 38a-514).

Thus, the state law goes beyond the federal law by applying to all individual and group plans (i. e. , it does not exempt small employers or employers who demonstrate a cost impact of 1% or more). Additionally, the state law does not permit any copays or limits for mental health services that are more restrictive than those applied to physical health services.

A health plan and a health insurer issuing individual or group health insurance coverage may not restrict benefits for a hospital length of stay in connection with childbirth for the mother or newborn child (1) following a normal vaginal delivery to less than 48 hours or (2) following a caesarean section to less than 96 hours. The plan or insurer may not require a provider to obtain authorization from it for prescribing such a length of stay. A provider, in consultation with the mother, may decide to discharge the mother or newborn before when the minimum length of stay expires.

The federal law does not apply to health insurance coverage if there is a state law that regulates the coverage if the state law requires (1) coverage of at least a 48-hour hospital length of stay following a normal vaginal delivery and at least a 96-hour hospital length of stay following a caesarean section, (2) coverage for maternity and pediatric care in accordance with guidelines established by established professional medical associations, or (3) the hospital length of stay decision is left to the attending provider in consultation with the mother.

Connecticut law requires each insurer and HMO offering health insurance coverage to comply with the federal requirements concerning newborns’ and mothers’ health (CGS § 38a-476a(b)).

In addition, each individual and group insurance carrier that offers maternity benefits must provide coverage of a minimum of 48 hours of inpatient care for a mother and her newborn following a vaginal delivery and 96 hours following a caesarean section (CGS §§ 38a-503c(b) and 38a-530c(b).

Any decision to shorten the length of stay must be made by the attending health care providers after conferring with the mother. If a mother and newborn are discharged earlier than the minimum time period, coverage must be provided for a follow-up visit within 48 hours of discharge and an additional follow-up visit within seven days of

discharge. Follow-up services must be (1) consistent with protocols and guidelines developed by attending providers or national professional medical organizations and (2) provided by qualified health care personnel trained in postpartum maternal and new born pediatric care (CGS §§ 503c(c) & (d) and 38a-530c(c) & (d)).

A group health plan is prohibited from reducing its coverage of pediatric vaccines below the coverage it provided as of May 1, 1993.

A group health policy must provide benefits for preventive pediatric care for any child covered by plan. Preventive pediatric care means the periodic review of a child’s physical and emotional health from birth through age six by or under a physician’s supervision. The review includes a medical history, complete physical examination, development assessment, anticipatory guidance, appropriate immunizations, and laboratory tests in keeping with prevailing medical standards. Benefits for preventive pediatric care are subject to any policy provisions that apply to other services covered by the policy (CGS § 38a-535).

Federal law defines a “pre-existing condition” as a condition for which medical advice, diagnosis, care, or treatment was recommended or received during the six-month period before a person’s health plan enrollment date. Group health plans and issuers are prohibited from excluding a person’s pre-existing medical condition from coverage for more than 12 months (18 months for late enrollees) after his enrollment date.

When a person enrolls in a new employer’s health plan, the plan must give him credit for the length of time he had prior continuous health coverage, without a break in coverage of 63 days or more, thereby reducing or eliminating the exclusion period for coverage of pre-existing conditions.

Pre-existing condition exclusions cannot be applied to pregnancy, regardless of whether the woman had previous health coverage. Genetic information may not be treated as a pre-existing condition in the absence of a diagnosis.

A pre-existing condition exclusion cannot be applied to a newborn, adopted child under age 18, or a child under age 18 placed for adoption as long as the child (1) became covered under health coverage within 30 days of his birth, adoption, or placement for adoption and (2) does not incur a subsequent 63-day break in coverage.

Connecticut law requires each insurer and HMO offering group health insurance coverage to comply with the federal requirements concerning pre-existing conditions, except that longer break-in-coverage time period applies, as explained below (CGS § 38a-476(e)). In addition, state law (1) applies pre-existing condition rules to individual health care plans and (2) prohibits pre-existing condition limitations greater than 12 months.

A group insurance plan is prohibited from excluding coverage for a pre-existing condition beyond 12 months following the insured’s effective date of coverage. A pre-existing condition under a group insurance plan is a condition for which medical advice, diagnosis, care, or treatment was recommended or received during the six-month period before a person’s coverage effective date (CGS § 38a-476(b)(1)).

An individual insurance plan is prohibited from excluding coverage for a pre-existing condition beyond 12 months following the insured’s effective date of coverage. A pre-existing condition under an individual insurance plan is a condition that manifested itself or for which medical advice, diagnosis, care, or treatment was recommended or received during the 12-month period before a person’s coverage effective date (CGS § 38a-476(b)(2)).

Both group and individual plans are prohibited from (1) considering pregnancy a pre-existing condition, (2) treating genetic information as a pre-existing condition in the absence of a diagnosis of the condition related to such information and (3) considering as medical advice, diagnosis, care, or treatment routine follow-up care to determine if breast cancer has reoccurred in a person who was previously determined to be free of breast cancer unless breast cancer is found during or as a result of such follow-up (CGS § 38a-476(a)(3)).

If a person’s prior plan covered his pre-existing condition, the succeeding plan must also cover the condition, provided (1) the prior “qualifying coverage” was continuous to a date not less than 120 days or, if the previous coverage was terminated due to an involuntary loss of employment, 150 days before the new plan’s effective date and (2) the person applies for the new coverage within 30 days of his initial eligibility (CGS § 38a-476(c)). “Qualifying coverage” means (1) any group health insurance plan, insurance arrangement, or self-insured plan; (2) Medicare or Medicaid; or (3) an individual health insurance plan that provides benefits actuarially equivalent to or exceeding the benefits provided by a small employer health care plan under state law (CGS § 38a-476(a)(4)).

If a person’s prior plan did not cover his pre-existing condition, the succeeding plan must credit against its pre-existing condition exclusion the time the person was previously covered under “qualifying coverage” provided (1) the prior coverage was continuous to a date not less than 120 days or, if the previous coverage was terminated due to an involuntary loss of employment, 150 days before the new plan’s effective date and (2) the person applies for the new coverage within 30 days of his initial eligibility (CGS § 38a-476(d)).

The state law does not apply to a short term health insurance policy issued on a non-renewable basis providing coverage for six months or less, as long as the application or sales brochure for the coverage discloses that pre-existing conditions are not covered (CGS § 38a-476(g)).

Under the federal Civil Rights Act, it is an unlawful employment practice for an employer to discriminate against a person on the basis of sex (42 U. S. C. § 2000e-2(a)). The 1981 Pregnancy Discrimination Act defines “on the basis of sex” to include on the basis of pregnancy, childbirth, or related medical conditions. It also requires employers to treat women affected by pregnancy, childbirth, or related medical conditions the same for all employment-related purposes, including fringe benefits, as others not affected by those conditions but similar in their ability to work.

Connecticut law requires that individual and group health insurance plans include pregnancy and resulting childbirth or miscarriage in the term “disease or injury” (CGS § 38a-551(r)). As a result, insurance plans that provide coverage for disease or injury cannot exclude benefits for pregnancy.

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¹ Omnibus Budget Reconciliation Act of 1993

² Health Insurance Portability and Accountability Act of 1996

³ Consolidated Omnibus Budget Reconciliation Act of 1985

⁴ Women’s Health and Cancer Rights Act of 1998

⁵ Mental Health Parity Act of 1996

⁶ Newborns’ and Mothers’ Health Protection Act of 1996

⁷ Pregnancy Discrimination Act of 1981