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-477c. Disclosure of medical loss ratio with each health insurance application.
Sec. 38a-478. Definitions.
Sec. 38a-478c. Managed care organization's report to the commissioner: Data, reports and information required.
Sec. 38a-478g. Managed care contract requirements. Plan description requirements.
Sec. 38a-478l. Consumer report card required. Content.
Sec. 38a-478n. Exhaustion of internal appeal mechanisms. External appeal to commissioner. Applicability to health insurers, managed care organizations and utilization review companies. Fees. Preliminary review. Full review. Public outreach program. Expedited external appeal. Requirements for and approval of independent review entities. Filing of report.
Sec. 38a-479. Definitions. Access to fee schedules. Fee information to be confidential.
Sec. 38a-479b. (Note: This section is effective July 1, 2010.) Material changes to fee schedules. Return of payment by provider. Appeals. Filing of claim by provider under other applicable insurance coverage.
Sec. 38a-481. (Formerly Sec. 38-165). Approval of individual health application, policy form and rates. Medicare supplement policies and certificates: Age, gender, previous claim or medical history rating prohibited. Loss ratios. Regulations. Certain refunds to be donated to The University of Connecticut Health Center. Underwriting classifications, claim experience and health status. Exceptions. Use of certain prescription drug history prohibited.
Sec. 38a-490a. Coverage for birth-to-three program.
Sec. 38a-492m. Mandatory coverage for certain renewals of prescription eye drops.
Sec. 38a-492n. Mandatory coverage for certain wound-care supplies.
Sec. 38a-497. (Formerly Sec. 38-174r). Termination of coverage of children in individual policies. Coverage for stepchildren.
Sec. 38a-503. (Formerly Sec. 38-174gg). Mandatory coverage for mammography and breast ultrasound. Breast density information included in mammography report.
Sec. 38a-513e. Premium payment by employer following employee termination. Exceptions.
Sec. 38a-514b. Coverage for autism spectrum disorders.
Sec. 38a-516a. Coverage for birth-to-three program.
Sec. 38a-518l. Mandatory coverage for certain renewals of prescription eye drops.
Sec. 38a-518m. Mandatory coverage for certain wound-care supplies.
Sec. 38a-530. Mandatory coverage for mammography and breast ultrasound. Breast density information included in mammography report.
Sec. 38a-554. (Formerly Sec. 38-374). Additional requirements and eligibility under group comprehensive health care plans. Coverage for stepchildren. Continuation of benefits under group plans. Insurance Commissioner's authority to coordinate benefits.

PART I
HEALTH INSURANCE: IN GENERAL

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

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

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

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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) of this section. The lien shall be effective against any workers' compensation award made after the notice is received.

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

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

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

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

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

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

      (P.A. 09-46, S. 2.)

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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) "Adverse determination" means a determination by a managed care organization, health insurer or utilization review company that an admission, service, procedure or extension of stay that is a covered benefit has been reviewed and, based upon the information provided, does not meet the managed care organization's, health insurer's or utilization review company's requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness, and such requested admission, service, procedure or extension of stay, or payment for such admission, service, procedure or extension of stay has been denied, reduced or terminated.

       (2) "Commissioner" means the Insurance Commissioner.

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

       (4) Except as provided in sections 38a-478m and 38a-478n, "enrollee" means a person who has contracted for or who participates in a managed care plan for such person or such person's eligible dependents.

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

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

       (7) "Managed care plan" means a product offered by a managed care organization that provides for the financing or delivery of health care services to persons enrolled in the plan through: (A) Arrangements with selected providers to furnish health care services; (B) explicit standards for the selection of participating providers; (C) financial incentives for enrollees to use the participating providers and procedures provided for by the plan; or (D) arrangements that share risks with providers, provided the organization offering a plan described under subparagraph (A), (B), (C) or (D) of this subdivision is licensed by the Insurance Department pursuant to chapter 698, 698a or 700 and the plan includes utilization review pursuant to sections 38a-226 to 38a-226d, inclusive.

       (8) "Preferred provider network" has the same meaning as provided in section 38a-479aa.

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

       (10) "Review entity" means an entity that conducts independent external reviews of adverse determinations. Such review entities include, but are not limited to, medical peer review organizations, independent utilization review companies, provided such organizations or companies are not related to or associated with any managed care organization or health insurer, and nationally recognized health experts or institutions approved by the Insurance Commissioner.

       (11) "Utilization review" has the same meaning as provided in section 38a-226.

       (12) "Utilization review company" has the same meaning as provided in section 38a-226.

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

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

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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 first of each year, each managed care organization shall submit to the commissioner:

       (1) A report on its quality assurance plan that includes, but is not limited to, information on complaints related to providers and quality of care, on decisions related to patient requests for coverage and on prior authorization statistics. Statistical information shall be submitted in a manner permitting comparison across plans and shall include, but not be limited to: (A) The ratio of the number of complaints received to the number of enrollees; (B) a summary of the complaints received related to providers and delivery of care or services and the action taken on the complaint; (C) the ratio of the number of prior authorizations denied to the number of prior authorizations requested; (D) the number of utilization review determinations made by or on behalf of a managed care organization not to certify an admission, service, procedure or extension of stay, and the denials upheld and reversed on appeal within the managed care organization's utilization review procedure; (E) the percentage of those employers or groups that renew their contracts within the previous twelve months; and (F) notwithstanding the provisions of this subsection, on or before July 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, as defined in subsection (b) of section 38a-478l, how it compensates health care providers and its premium level; (C) a description of services, the number of primary care physicians and specialists, the number and nature of participating preferred provider networks and the distribution and number of hospitals, by county; (D) utilization review information, including the name or source of any established medical protocols and the utilization review standards; (E) medical management information, including the provider-to-patient ratio by primary care provider and 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; P.A. 09-46, S. 3.)

      History: P.A. 98-27 amended Subpara. (a)(1)(F) to add "Notwithstanding the provisions of this subsection, on or before July 1, 1998, and annually thereafter" re required data; P.A. 03-169 amended Subsec. (a) to reword Subdiv. (1)(D) re utilization review determinations, to add in Subdivs. (2) and (3) reference to preferred provider networks, to substitute "required" for "he is required to develop and distribute" in Subdiv. (4) and to add "the number and nature of participating preferred provider networks" in Subpara. (C), and make conforming changes; P.A. 09-46 amended Subsec. (a) to make a technical change and, in Subdiv. (4)(B), to replace provision re percentage of total premium revenues with definition of medical loss ratio in Sec. 38a-478l(b).

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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 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, as defined in subsection (b) of section 38a-478l, as reported in the last Consumer Report Card on Health Insurance Carriers in Connecticut;

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

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

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

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

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

       (15) Enrollee satisfaction information; and

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

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

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

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

       (b) The consumer report card shall be known as the "Consumer Report Card on Health Insurance Carriers in Connecticut" and shall include (1) all health care centers licensed pursuant to chapter 698a, (2) the fifteen largest licensed health insurers that use provider networks and that are not included in subdivision (1) of this subsection, (3) the medical loss ratio of each such health care center or licensed health insurer, and (4) information concerning mental health services, as specified in subsection (c) of this section. 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. For the purposes of this section and sections 38a-477c, 38a-478c and 38a-478g, "medical loss ratio" means the ratio of incurred claims to earned premiums for the prior calendar year for managed care plans issued in the state. Claims shall be limited to medical expenses for services and supplies provided to enrollees and shall not include expenses for stop loss coverage, reinsurance, enrollee educational programs or other cost containment programs or features.

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

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

      (P.A. 97-99, S. 13; P.A. 06-188, S. 34; P.A. 07-217, S. 156; P.A. 09-46, S. 1.)

      History: P.A. 06-188 added Subsec. (b)(3) re information concerning mental health services specified in new Subsec. (c), added new Subsec. (c) to require inclusion of specific mental health related information in consumer report card and redesignated existing Subsec. (c) as Subsec. (d); P.A. 07-217 made a technical change in Subsec. (c), effective July 12, 2007; P.A. 09-46 amended Subsec. (a) to replace provision re March 15 annual deadline with provision re October 15 annual deadline, amended Subsec. (b) to specify name by which consumer report card shall be known, define "medical loss ratio" and add same to list of information included in consumer report card, and amended Subsec. (d) to require Insurance Department to prominently display a link to consumer report card on its web site.

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      Sec. 38a-478n. Exhaustion of internal appeal mechanisms. External appeal to commissioner. Applicability to health insurers, managed care organizations and utilization review companies. Fees. Preliminary review. Full review. Public outreach program. Expedited external appeal. Requirements for and approval of independent review entities. Filing of report. (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, health insurer 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. As used in this section and section 38a-478m, "health insurer" means any entity, other than a managed care organization that delivers, issues for delivery, renews, amends or continues an individual or group health insurance plan in this state providing coverage of the type specified in subdivision (1), (2), (4), (10), (11), (12) and (13) of section 38a-469, and "enrollee" means a person who has contracted for or who participates in coverage under an individual or group health insurance plan or a managed care plan for such person or such person's eligible dependents.

      (b) (1) To appeal a denial or determination pursuant to this section, an enrollee or any provider acting on behalf of an enrollee with the enrollee's consent shall, not later than sixty days after receiving final written notice of the denial or determination from the enrollee's managed care organization, health insurer 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, health insurer 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. If the Insurance Commissioner receives three or more appeals of denials or determinations by the same managed care organization or utilization review company with respect to the same procedural or diagnostic coding, the Insurance Commissioner may, on said commissioner's own motion, issue an order specifying how such managed care organization or utilization review company shall make determinations about such procedural or diagnostic coding.

       (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, health insurer 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 a review entity.

       (4) Upon receipt of the request for appeal from the commissioner, the review entity conducting the appeal shall conduct a preliminary review of the appeal and accept the appeal if such review entity determines: (A) The individual was or is an enrollee of the managed care organization or health insurer; (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 or provider acting on behalf of the enrollee with the enrollee's consent has exhausted all internal appeal mechanisms provided; (D) the enrollee or provider acting on behalf of the enrollee with the enrollee's consent 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 or health insurer and any other relevant provider.

       (5) Upon completion of the preliminary review, the review entity shall immediately notify the enrollee 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, (A) the review 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, and (B) the commissioner shall notify the managed care organization, health insurer or utilization review company of the receipt of a request for an external appeal and provide the name of the review entity assigned to such appeal. Not later than five business days after such notification, the managed care organization, health insurer or utilization review company shall provide to such review entity by electronic mail, telephone, facsimile or other expeditious method all documents and information that were considered in making the adverse determination that is the subject of such appeal.

       (c) (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 or health insurer 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 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 or health insurer 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 or health insurer, except that with respect to a self-insured governmental plan, (i) the managed care organization or health insurer shall notify the plan sponsor, and (ii) the plan sponsor shall send, or require the managed care organization or health insurer 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 or contract.

       (2) Failure of the managed care organization or health insurer to provide information or notify the plan sponsor in accordance with subdivision (1) of this subsection within said five-business-day period 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 or health insurer 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.

       (d) 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 Healthcare Advocate shall coordinate the outreach program and oversee the education process.

       (e) (1) (A) Except as provided in subdivision (9) of this subsection, an enrollee or any provider acting on behalf of the enrollee with the enrollee's consent may make a request to the commissioner for an expedited external appeal at the time the enrollee receives an adverse determination if: (i) The time frame for completion of an expedited internal appeal set forth in section 38a-226c may cause or exacerbate an emergency or life-threatening situation for the enrollee; and (ii) the enrollee or the provider acting on behalf of the enrollee with the enrollee's consent has filed a request for expedited review as set forth in section 38a-226c.

       (B) Upon receipt of such request and all required documentation, including the executed release and appropriate fee set forth in subsection (b) of this section, the commissioner shall immediately assign the appeal for review to a review entity.

       (2) Upon receipt of the request for an expedited external appeal from the commissioner, the review entity shall, not later than two business days after receipt of such appeal, conduct a preliminary review of the appeal and accept the appeal for expedited review if such review entity determines: (A) The individual was or is an enrollee of the managed care organization or health insurer; (B) the benefit or service that is the subject of the appeal reasonably appears to be a covered service, benefit or service under the agreement provided by contract to the enrollee; (C) the enrollee or provider acting on behalf of the enrollee with the enrollee's consent has provided all information required by the commissioner to make a preliminary determination including the appeal form, a copy of the decision of denial and a fully-executed release to obtain any necessary medical records from the managed care organization or health insurer and any other relevant provider; and (D) the adverse determination may cause or exacerbate an emergency or life-threatening situation for the enrollee if not reviewed in an expedited time period.

       (3) Upon completion of the preliminary review, the review entity shall immediately notify the enrollee 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.

       (4) If accepted for full review, the review entity shall conduct such review to determine whether the adverse determination should be reversed, revised or affirmed. Such review shall be performed by a provider who is a specialist in the field related to the condition that is the subject of the appeal. The review entity may take into consideration: (A) Pertinent medical records; (B) consulting reports from appropriate health care professionals and other documents submitted by the health insurer, the enrollee, the enrollee's authorized representative or the enrollee's provider; (C) practice guidelines developed by the federal government or national, state or local medical societies, boards or associations; and (D) clinical protocols or practice guidelines developed by the managed care organization, health insurer or utilization review company. For the purposes of this subdivision, "authorized representative" means (i) a person to whom an enrollee has given express written consent to represent such enrollee in an external appeal, (ii) a person authorized by law to provide substituted consent for an enrollee, or (iii) a family member of the enrollee when such enrollee is unable to provide consent.

       (5) To the extent the following information or documents are available and the review entity considers them appropriate, such review entity shall consider:

       (A) The terms of coverage under the agreement provided by contract to the enrollee to ensure the review entity's decision is not contrary to the terms of coverage under such agreement;

       (B) Medical or scientific evidence. For the purposes of this subparagraph, "medical or scientific evidence" means evidence found in the following sources:

       (i) Peer-reviewed scientific studies published in or accepted for publication by medical journals that meet nationally recognized requirements for scientific manuscripts and that submit most of their published articles for review by experts who are not part of the editorial staff;

       (ii) Peer-reviewed medical literature, including literature relating to therapies reviewed and approved by a qualified institutional review board, biomedical compendia and other medical literature that meet the criteria of the National Institutes of Health's National Library of Medicine for indexing in Index Medicus (MEDLINE) or Elsevier Science for indexing in Excerpta Medica (EMBASE);

       (iii) Medical journals recognized by the Secretary of Health and Human Services under Section 1861(t)(2) of the Social Security Act;

       (iv) The following standard reference compendia: (I) The American Hospital Formulary Service - Drug Information; (II) Drug Facts and Comparisons; (III) the American Dental Association's Accepted Dental Therapeutics; and (IV) the United States Pharmacopoeia - Drug Information; and

       (v) Findings, studies or research conducted by or under the auspices of federal government agencies or nationally recognized federal research institutes including (I) the Agency for Healthcare Research and Quality, (II) the National Institutes of Health, (III) the National Cancer Institute, (IV) the National Academy of Sciences, (V) the Centers for Medicare and Medicaid Services, (VI) the Food and Drug Administration, (VII) any national board recognized by the National Institutes of Health to evaluate the medical value of health care services, and (VIII) any other source that is comparable to those listed in subparagraphs (B)(v)(I) to (B)(v)(V), inclusive, of this subdivision;

       (C) Any applicable clinical review criteria developed and used by the managed care organization, health insurer or utilization review company in making adverse determinations; and

       (D) After considering subparagraphs (A) to (C), inclusive, of this subdivision, the opinion of the review entity's clinical reviewer or reviewers.

       (6) The review entity shall complete its full review not later than two business days after the completion of its preliminary review and shall forward its decision to reverse, revise or affirm the adverse determination together with its report of the full review to the commissioner. The review entity may request from the commissioner an extension of time to complete its review due to circumstances beyond its control. If an extension is granted, the review entity shall provide written notice to the enrollee or the enrollee's provider, setting forth the status of the review, the specific reasons for the delay and the anticipated date of completion of the review.

       (7) In reaching a decision under subdivision (6) of this subsection, a review entity shall not be bound by any decisions or conclusions reached by the managed care organization, health insurer or utilization review company pursuant to section 38a-226c or this section.

       (8) The commissioner shall notify the managed care organization, health insurer or utilization review company of the receipt of a request for an expedited external appeal and provide the name of the review entity assigned to such appeal. Not later than one business day after such notification, the managed care organization, health insurer or utilization review company shall provide to such review entity by electronic mail, telephone, facsimile or other expeditious method all documents and information that were considered in making the adverse determination that is the subject of such appeal.

       (9) The commissioner shall not provide an expedited external appeal if the health care services that are the subject of the appeal have already been provided to the enrollee.

       (10) If a request for an expedited external appeal is denied, an enrollee or any provider acting on behalf of the enrollee with the consent of the enrollee may submit such request for a standard external appeal as set forth in subsection (b) of this section.

       (11) The commissioner shall assign review entities to appeals on a random basis and shall choose such entities from among those approved by the Insurance Commissioner, after consultation with the Commissioner of Public Health, as set forth in subsection (g) of this section.

       (f) (1) An external appeal decision shall be binding on the managed care organization, health insurer, utilization review company and enrollee. Nothing in this subdivision shall be construed to limit or prohibit any other remedy available under federal or state law.

       (2) No enrollee or provider acting on behalf of the enrollee with the enrollee's consent shall file a subsequent request for external appeal involving the same adverse determination for which the enrollee has already received an external appeal pursuant to this section.

       (g) (1) After consultation with the Commissioner of Public Health, the Insurance Commissioner shall engage independent review entities to provide medical review under the provisions of this section.

       (2) (A) (i) To be eligible for approval by the commissioner, a review entity shall have received approval or accreditation by a nationally recognized private accrediting review entity approved by the commissioner, or shall demonstrate to the commissioner that such review entity adheres to qualifications that are substantially similar to, and do not provide less protection to enrollees than, those set forth in subsection (h) of this section.

       (ii) A review entity that is accredited by a nationally recognized private accrediting review entity that has independent review accreditation standards, which the commissioner has determined are equivalent to or exceed the minimum qualifications of subsection (h) of this section, shall be deemed to be eligible for approval by the commissioner.

       (B) Each review entity shall provide a statement of qualifications to the commissioner in accordance with state and Insurance Department contracting requirements.

       (3) Each approval shall be effective for two years, unless the commissioner determines before its expiration that the review entity is not satisfying the minimum qualifications set forth in subsection (h) of this section. If the commissioner determines that a review entity is not satisfying such minimum qualifications, the commissioner shall terminate the review entity's contract.

       (h) (1) Each review entity approved by the commissioner pursuant to subsection (g) of this section shall have and maintain written policies and procedures that govern all aspects of the standard and expedited external appeal processes set forth in subsections (b) and (e) of this section, including, but not limited to:

       (A) A quality assurance mechanism that ensures: (i) That external appeals are conducted within the time frames specified and required notices are provided in a timely manner; (ii) the selection and employment of qualified, impartial and sufficient number of clinical reviewers to conduct external appeals on behalf of the review entity and suitable matching of reviewers to specific cases; (iii) the confidentiality of medical and treatment records and clinical review criteria; and (iv) that any person employed by or under contract with the review entity complies with the provisions of this section;

       (B) A toll-free facsimile service or electronic mail that is able to receive information related to external appeals on a twenty-four-hours-per-day, seven-days-per-week basis; and

       (C) An agreement to maintain and provide to the commissioner the information required in subsection (j) of this section.

       (2) Each clinical reviewer assigned by a review entity to conduct external appeals shall be a physician or other health care provider who meets the following minimum qualifications:

       (A) Is an expert in the treatment of the enrollee's medical condition that is the subject of the external appeal;

       (B) Is knowledgeable about the recommended health care service or treatment through recent or current actual clinical experience treating patients with the same or similar medical condition as the enrollee;

       (C) Holds a nonrestricted license in a state of the United States and, for a physician, holds a current certification by a recognized American medical specialty board in the area or areas appropriate to the subject of the external appeal; and

       (D) Has no history of disciplinary actions or sanctions, including loss of staff privileges or participation restrictions, taken or pending by any hospital, governmental agency or unit or regulatory body, that raise a substantial question as to the physical, mental or professional competence or moral character of such reviewer.

       (3) In addition to the requirements set forth in subdivision (1) of this subsection, a review entity shall not own or control, be a subsidiary of or be owned or controlled by, or exercise control over a managed care organization, health insurer, utilization review company, health plan, a national, state or local trade association of managed care organizations or health insurers or a national, state or local trade association of health care providers.

       (4) (A) Neither the review entity assigned by the commissioner to conduct an external appeal nor any clinical reviewer assigned by the review entity to conduct such appeal shall have a material professional, familial or financial conflict of interest with any of the following:

       (i) The managed care organization, health insurer or utilization review company that is the subject of the external appeal;

       (ii) The enrollee whose treatment is the subject of the external appeal or the provider acting on behalf of the enrollee with the enrollee's consent;

       (iii) Any officer, director or management employee of the managed care organization, health insurer or utilization review company that is the subject of the external appeal;

       (iv) The health care provider, the health care provider's medical group or independent practice association recommending the health care service or treatment that is the subject of the external appeal;

       (v) The facility at which the recommended health care service or treatment would be provided. For the purposes of this subparagraph, "facility" means an institution providing health care services or a health care setting, including, but not limited to, hospitals and other licensed inpatient centers, ambulatory surgical or treatment centers, skilled nursing centers, residential treatment centers, diagnostic, laboratory and imaging centers, and rehabilitative or other therapeutic health settings; or

       (vi) The developer or manufacturer of the principal drug, device, procedure or other therapy being recommended for the enrollee whose treatment is the subject of the external appeal.

       (B) When determining whether a review entity or clinical reviewer has a material professional, familial or financial conflict of interest, the commissioner shall take into consideration situations in which the review entity or clinical reviewer to be assigned to conduct an external appeal may have an apparent professional, familial or financial relationship or connection with a person described in subparagraph (A) of this subdivision but that the characteristics of such relationship or connection are such that they do not constitute a material conflict of interest that disqualifies the review entity or clinical reviewer from being assigned to the specific case.

       (5) A review entity shall be unbiased and shall establish and maintain written procedures to ensure such impartiality, in addition to any other procedures required to be maintained by this section.

       (i) No review entity or clinical reviewer working on behalf of a review entity, or an employee, agent or contractor of a review entity shall be liable in damages to any person for any opinion rendered or act or omission performed within the scope of the review entity's or such employee's, agent's or contractor's duties during or upon completion of an external appeal conducted pursuant to this section, unless such opinion was rendered or act or omission was performed in bad faith or involved gross negligence.

       (j) (1) Each review entity shall maintain written records for review by a managed care organization, health insurer or utilization review company on all requests for standard and expedited external appeals for which such entity conducted such reviews during a calendar year. The review entity shall retain such written records for at least six years.

       (2) Each review entity shall submit a report to the commissioner upon request, in a format prescribed by the commissioner. Such report shall include, for each managed care organization, health insurer and utilization review company:

       (A) The total number of requests for standard external appeals and the total number of requests for expedited external appeals;

       (B) The number of standard external appeals and the number of expedited external appeals that were resolved, and of those resolved, the number reversing the adverse determination, the number revising the adverse determination and the number affirming the adverse determination;

       (C) The length of time for resolution of each external appeal;

       (D) A summary of the procedure and diagnosis codes for which an external appeal was sought; and

       (E) Any other information the commissioner may require.

      (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; P.A. 05-29, S. 1; 05-94, S. 3; 05-102, S. 1, 5; P.A. 06-54, S. 4; P.A. 07-75, S. 3; P.A. 08-147, S. 7; P.A. 09-49, S. 2.)

      History: June 18 Sp. Sess. P.A. 97-8 amended Subsec. (b)(2) 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; P.A. 05-29 amended Subsec. (d)(1)(C)to add "or contract"; P.A. 05-94 amended Subsec. (a) to define "health insurer", "health plan" and "enrollee", referenced health insurers throughout, and amended Subsec. (d) to change "managed care plan" to "plan", reference "or contract" and delete references to "self-insured governmental plan" and notice to and from "plan sponsor", effective July 1, 2005; P.A. 05-102 amended Subsec. (b)(1) by authorizing commissioner to issue order with respect to multiple appeals of same procedural or diagnostic coding and amended Subsec. (f) by renaming the Managed Care Ombudsman the Healthcare Advocate; P.A. 06-54 amended Subsec. (d)(1) to require managed care organization or health insurer to send commissioner written certifications and a copy of entire policy or contract between enrollee and such organization or insurer if plan is a self-insured governmental plan, but with respect to sending such copy, organization or insurer shall notify plan sponsor who shall send or require such organization or insurer to send such copy, and amended Subsec. (d)(2) to provide that failure of managed care organization or health insurer to notify plan sponsor within five-business-day period or before thirty-day appeal period ends, whichever is later as determined by commissioner, shall have consequences specified in Subparas. (A) and (B) of said Subdiv., effective May 8, 2006; P.A. 07-75 amended Subsecs. (b)(1) and (d)(2) to extend the time to file an appeal with commissioner from 30 to 60 days, effective May 30, 2007; P.A. 08-147 amended Subsec. (d)(2) by deleting provision re 60-day period for insurers to provide information or notify plan sponsor of evidence of coverage; P.A. 09-49 redefined "health insurer" and "enrollee" and deleted term "health plan" in Subsec. (a), amended Subsec. (b) to permit provider to act on behalf of enrollee and to specify notification and documentation requirements, deleted former Subsec. (c) re entities providing medical review, redesignated existing Subsec. (d) as Subsec. (c), deleted former Subsec. (e) re acceptance of review entity's decision, redesignated existing Subsec. (f) as Subsec. (d) and added new Subsec. (e) re expedited external appeal procedures, new Subsec. (f) re external appeal decisions, Subsec. (g) re requirements for and approval of review entities, Subsec. (h) re written policies and procedures of review entities, Subsec. (i) re liability and Subsec. (j) re records and reports.

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

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

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

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

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

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

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

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

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

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

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      Sec. 38a-479b. (Note: This section is effective July 1, 2010.) Material changes to fee schedules. Return of payment by provider. Appeals. Filing of claim by provider under other applicable insurance coverage. (a) No contracting health organization shall make material changes to a provider's fee schedule except as follows:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

      (P.A. 09-204, S. 2.)

      History: P.A. 09-204 effective July 1, 2010.

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PART II
INDIVIDUAL HEALTH INSURANCE

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

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

       (c) No insurance company, fraternal benefit society, hospital service corporation, medical service corporation, health care center or other entity which delivers or issues for delivery in this state any Medicare supplement policies or certificates shall incorporate in its rates or determinations to grant coverage for Medicare supplement insurance policies or certificates any factors or values based on the age, gender, previous claims history or the medical condition of any person covered by such policy or certificate, 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 determinations to grant coverage under Medicare supplement policies and certificates issued prior to January 1, 2006.

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

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

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

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

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

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

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

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

       (f) For the purposes of this section:

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

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

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

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

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

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

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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 six thousand four hundred dollars per child per year and an aggregate benefit of nineteen thousand two hundred dollars per child over the total three-year period. 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; Sept. Sp. Sess. P.A. 09-3, S. 46.)

      History: P.A. 96-185 effective July 1, 1996; June 30 Sp. Sess. P.A. 03-3 deleted provision re coverage for at least $5,000 annually, added Subdivs. (1) and (2) re coverage and benefits to be provided by policy and made technical changes, effective August 20, 2003; Sept. Sp. Sess. P.A. 09-3 amended Subdiv. (2) by increasing per child per year benefit from $3,200 to $6,400 and by increasing 3-year per child aggregate benefit from $9,600 to $19,200, effective October 6, 2009.

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      Sec. 38a-492m. Mandatory coverage for certain renewals of prescription eye drops. Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state on or after January 1, 2010, that provides coverage for prescription eye drops, shall not deny coverage for a renewal of prescription eye drops when (1) the renewal is requested by the insured less than thirty days from the later of (A) the date the original prescription was distributed to the insured, or (B) the date the last renewal of such prescription was distributed to the insured, and (2) the prescribing physician indicates on the original prescription that additional quantities are needed and the renewal requested by the insured does not exceed the number of additional quantities needed.

      (P.A. 09-136, S. 1.)

      History: P.A. 09-136 effective January 1, 2010.

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      Sec. 38a-492n. Mandatory coverage for certain wound-care supplies. Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 that is delivered, issued for delivery, renewed, amended or continued in this state on or after January 1, 2010, shall provide coverage for wound-care supplies that are medically necessary for the treatment of epidermolysis bullosa and are administered under the direction of a physician.

      (P.A. 09-51, S. 1.)

      History: P.A. 09-51 effective January 1, 2010.

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      Sec. 38a-497. (Formerly Sec. 38-174r). Termination of coverage of children in individual policies. Coverage for stepchildren. 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, renewed or continued in this state shall provide that coverage of a child shall terminate no earlier than the policy anniversary date on or after whichever of the following occurs first, the date on which the child: Marries; ceases to be a resident of the state; becomes covered under a group health plan through the dependent's own employment; or attains the age of twenty-six. The residency requirement shall not apply to dependent children under nineteen years of age or full-time students attending an accredited institution of higher education. Each such policy shall cover a stepchild on the same basis as a biological child.

      (P.A. 82-143; P.A. 90-243, S. 87; P.A. 07-185, S. 16; June Sp. Sess. P.A. 07-2, S. 64, 69; P.A. 08-147, S. 8; P.A. 09-124, S. 1.)

      History: P.A. 90-243 substituted reference to health insurance policies for reference to hospital or medical expense policies and contracts and specified applicability solely to individual policies; Sec. 38-174r transferred to Sec. 38a-497 in 1991; P.A. 07-185 prohibited termination of coverage of a child prior to the policy anniversary date on or after the earliest of the date on which the child marries, ceases to be a resident of the state or attains the age of 26, for any policy delivered, issued for delivery, amended or renewed on or after October 1, 2007, effective July 1, 2007; June Sp. Sess. P.A. 07-2 changed effective date of P.A. 07-185, S. 16 to January 1, 2009, effective June 26, 2007, and applied provisions to policies delivered, issued for delivery, amended or renewed in this state on or after January 1, 2009, and made provisions allowing children to maintain coverage until age 26 contingent upon children remaining state residents, except for full-time attendance at an out-of-state accredited institution of higher education or residency with a custodial parent pursuant to a child custody determination, effective January 1, 2009; P.A. 08-147 revised conditions upon which coverage of a child terminates by adding provision re coverage under a group health plan through a dependent child's own employment, deleting custodial parent provision, and specifying that dependent children to age 19 are exempt from state residency requirement, effective January 1, 2009; P.A. 09-124 inserted "or continued", made a technical change and added requirement that a stepchild be covered on the same basis as a biological child, effective June 18, 2009.

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      Sec. 38a-503. (Formerly Sec. 38-174gg). Mandatory coverage for mammography and breast ultrasound. Breast density information included in mammography report. (a) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state 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 policy shall provide additional benefits for comprehensive ultrasound screening of an entire breast or breasts if a mammogram demonstrates heterogeneous or dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology or if a woman is believed to be at increased risk for breast cancer due to family history or prior personal history of breast cancer, positive genetic testing or other indications as determined by a woman's physician or advanced practice registered nurse.

       (b) Benefits under this section shall be subject to any policy provisions that apply to other services covered by such policy.

       (c) On and after October 1, 2009, each mammography report provided to a patient shall include information about breast density, based on the Breast Imaging Reporting and Data System established by the American College of Radiology. Where applicable, such report shall include the following notice: "If your mammogram demonstrates that you have dense breast tissue, which could hide small abnormalities, you might benefit from supplementary screening tests, which can include a breast ultrasound screening or a breast MRI examination, or both, depending on your individual risk factors. A report of your mammography results, which contains information about your breast density, has been sent to your physician's office and you should contact your physician if you have any questions or concerns about this report.".

      (P.A. 88-124, S. 1; P.A. 90-243, S. 93; P.A. 01-171, S. 22; P.A. 05-69, S. 1; P.A. 06-38, S. 1; P.A. 09-41, S. 1.)

      History: P.A. 90-243 substituted reference to health insurance policies for references to hospital or medical expense policies and contracts and specified applicability solely to individual policies; Sec. 38-174gg transferred to Sec. 38a-503 in 1991; P.A. 01-171 added "amended or continued" re policies in this state, substituted "October 1, 2001," for "October 1, 1988," re policy date, consolidated Subdivs. (2) and (3) to provide annual coverage for any woman who is forty or over rather than coverage every two years for women 40 to 49 and annually thereafter, and substituted "each" for "every"; P.A. 05-69 added Subsec. designators (a) and (b), amended Subsec. (a) to require benefits for comprehensive ultrasound screening for certain women if recommended by a physician, and made technical changes in Subsec. (b); P.A. 06-38 amended Subsec. (a) to require policy to provide additional benefits for comprehensive ultrasound screening of an entire breast or breasts if mammogram demonstrates heterogeneous or dense breast tissue based on the BIRAD System or if a woman is believed to be at increased risk for breast cancer due to family history or prior personal history of breast cancer, positive genetic testing or other indications determined by a physician or advanced practice registered nurse, eliminating reference to screening recommended by a physician for a woman classified as a category 2, 3, 4 or 5 under such system; P.A. 09-41 added Subsec. (c) re breast density information required to be provided to a patient and notice where applicable.

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PART III
GROUP HEALTH INSURANCE

      Sec. 38a-513e. Premium payment by employer following employee termination. Exceptions. (a) In the event (1) an employer, as defined in section 31-58, terminates an employee for any reason other than layoff, or (2) an employee voluntarily terminates employment with an employer, such employer may elect not to pay the premium for such employee and any such employee's dependents under a group health insurance policy after the date of such employee's termination. In the event such employer makes such election, any insurer, health care center, hospital or medical service corporation or fraternal benefit society that issues such group health insurance policy shall credit such employer the amount of any premium paid by such employer with respect to such policy for such employee and such employee's dependents attributable to the period after the date of such employee's termination, provided the employer notifies the insurer, health care center, hospital or medical service corporation or fraternal benefit society that issued such policy and the terminated employee not later than seventy-two hours after the termination. Upon the issuance or renewal of such policy, such insurer, health care center, hospital or medical service corporation or fraternal benefit society shall provide such employer with relevant information related to such employer's election, including a notice that it is the employer's responsibility to remit to the terminated employee such employee's portion of the credited premium. Any such credit shall be applied to the employer's next month's premium. In the event of nonrenewal of such policy, the insurer, health care center, hospital or medical service corporation or fraternal benefit society shall refund such credit to the employer.

       (b) Notwithstanding the provisions of subsection (a) of this section, (1) any contractual agreement entered into through collective bargaining that requires the employer to pay the premium for an employee under a group health insurance policy after the date of such employee's termination shall supersede the provisions of subsection (a) of this section, and (2) no credit shall be available to an employer for any employee's and employee's dependents' coverage for the seventy-two hours immediately following the termination of such employee.

      (P.A. 09-126, S. 1.)

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      Sec. 38a-514b. Coverage for autism spectrum disorders. (a) As used in this section:

       (1) "Applied behavior analysis" means the design, implementation and evaluation of environmental modifications, using behavioral stimuli and consequences, including the use of direct observation, measurement and functional analysis of the relationship between environment and behavior, to produce socially significant improvement in human behavior.

       (2) "Autism services provider" means any person, entity or group that provides treatment for autism spectrum disorders pursuant to this section.

       (3) "Autism spectrum disorders" means the pervasive developmental disorders set forth in the most recent edition of the American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Disorders", including, but not limited to, Autistic Disorder, Rett's Disorder, Childhood Disintegrative Disorder, Asperger's Disorder and Pervasive Developmental Disorder Not Otherwise Specified.

       (4) "Behavioral therapy" means any interactive behavioral therapies derived from evidence-based research, including, but not limited to, applied behavior analysis, cognitive behavioral therapy, or other therapies supported by empirical evidence of the effective treatment of individuals diagnosed with an autism spectrum disorder, that are: (A) Provided to children less than fifteen years of age, and (B) provided or supervised by (i) a behavior analyst who is certified by the Behavior Analyst Certification Board, (ii) a licensed physician, or (iii) a licensed psychologist. For the purposes of this subdivision, behavioral therapy is "supervised by" such behavior analyst, licensed physician or licensed psychologist when such supervision entails at least one hour of face-to-face supervision of the autism services provider by such behavior analyst, licensed physician or licensed psychologist for each ten hours of behavioral therapy provided by the supervised provider.

       (5) "Diagnosis" means the medically necessary assessment, evaluation or testing performed by a licensed physician, licensed psychologist or licensed clinical social worker to determine if an individual has an autism spectrum disorder.

       (b) Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 that is delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for the diagnosis and treatment of autism spectrum disorders. For the purposes of this section and section 38a-513c, an autism spectrum disorder shall be considered an illness.

       (c) Such policy shall provide coverage for the following treatments, provided such treatments are (1) medically necessary, and (2) identified and ordered by a licensed physician, licensed psychologist or licensed clinical social worker for an insured who is diagnosed with an autism spectrum disorder, in accordance with a treatment plan developed by a licensed physician, licensed psychologist or licensed clinical social worker pursuant to a comprehensive evaluation or reevaluation of the insured:

       (A) Behavioral therapy;

       (B) Prescription drugs, to the extent prescription drugs are a covered benefit for other diseases and conditions under such policy, prescribed by a licensed physician, licensed physician assistant or advanced practice registered nurse for the treatment of symptoms and comorbidities of autism spectrum disorders;

       (C) Direct psychiatric or consultative services provided by a licensed psychiatrist;

       (D) Direct psychological or consultative services provided by a licensed psychologist;

       (E) Physical therapy provided by a licensed physical therapist;

       (F) Speech and language pathology services provided by a licensed speech and language pathologist; and

       (G) Occupational therapy provided by a licensed occupational therapist.

       (d) Such policy may limit the coverage for behavioral therapy to a yearly benefit of fifty thousand dollars for a child who is less than nine years of age, thirty-five thousand dollars for a child who is at least nine years of age and less than thirteen years of age and twenty-five thousand dollars for a child who is at least thirteen years of age and less than fifteen years of age.

       (e) Such policy shall not impose (1) any limits on the number of visits an insured may make to an autism services provider pursuant to a treatment plan on any basis other than a lack of medical necessity, or (2) a coinsurance, copayment, deductible or other out-of-pocket expense for such coverage that places a greater financial burden on an insured for access to the diagnosis and treatment of an autism spectrum disorder than for the diagnosis and treatment of any other medical, surgical or physical health condition under such policy.

       (f) (1) Except for treatments and services received by an insured in an inpatient setting, an insurer, health care center, hospital service corporation, medical service corporation or fraternal benefit society may review a treatment plan developed as set forth in subsection (c) of this section for such insured, in accordance with its utilization review requirements, not more than once every six months unless such insured's licensed physician, licensed psychologist or licensed clinical social worker agrees that a more frequent review is necessary or changes such insured's treatment plan.

       (2) For the purposes of this section, the results of a diagnosis shall be valid for a period of not less than twelve months, unless such insured's licensed physician, licensed psychologist or licensed clinical social worker determines a shorter period is appropriate or changes the results of such insured's diagnosis.

       (g) Coverage required under this section may be subject to the other general exclusions and limitations of the group health insurance policy, including, but not limited to, coordination of benefits, participating provider requirements, restrictions on services provided by family or household members and case management provisions, except that any utilization review shall be performed in accordance with subsection (f) of this section.

       (h) (1) Nothing in this section shall be construed to limit or affect (A) any other covered benefits available to an insured under (i) such group health insurance policy, (ii) section 38a-514, or (iii) section 38a-516a, (B) any obligation to provide services to an individual under an individualized education program pursuant to section 10-76d, or (C) any obligation imposed on a public school by the Individual With Disabilities Education Act, 20 USC 1400 et seq., as amended from time to time.

       (2) Nothing in this section shall be construed to require such group health insurance policy to provide reimbursement for special education and related services provided to an insured pursuant to section 10-76d, unless otherwise required by state or federal law.

      (P.A. 08-132, S. 2; P.A. 09-115, S. 1.)

      History: P.A. 08-132 effective January 1, 2009; P.A. 09-115 designated existing provisions as Subsec. (b) and amended same by changing coverage from "for physical therapy, speech therapy and occupational therapy services" to "the diagnosis and treatment" of autism spectrum disorders, making conforming changes and adding provision re autism spectrum disorder to be considered an illness, and added Subsec. (a) re definitions, Subsec. (c) re types of treatment and Subsecs. (d) to (h) re limits on coverage, review and exceptions, effective January 1, 2010.

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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 six thousand four hundred dollars per child per year and an aggregate benefit of nineteen thousand two hundred dollars per child over the total three-year period. 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; Sept. Sp. Sess. P.A. 09-3, S. 45.)

      History: P.A. 96-185 effective July 1, 1996; June 30 Sp. Sess. P.A. 03-3 deleted provision re coverage for at least $5,000 annually, added Subdivs. (1) and (2) re coverage and benefits to be provided by policy and made technical changes, effective August 20, 2003; Sept. Sp. Sess. P.A. 09-3 amended Subdiv. (2) by increasing per child per year benefit from $3,200 to $6,400 and by increasing 3-year per child aggregate benefit from $9,600 to $19,200, effective October 6, 2009.

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      Sec. 38a-518l. Mandatory coverage for certain renewals of prescription eye drops. Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state on or after January 1, 2010, that provides coverage for prescription eye drops, shall not deny coverage for a renewal of prescription eye drops when (1) the renewal is requested by the insured less than thirty days from the later of (A) the date the original prescription was distributed to the insured, or (B) the date the last renewal of such prescription was distributed to the insured, and (2) the prescribing physician indicates on the original prescription that additional quantities are needed and the renewal requested by the insured does not exceed the number of additional quantities needed.

      (P.A. 09-136, S. 2.)

      History: P.A. 09-136 effective January 1, 2010.

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      Sec. 38a-518m. Mandatory coverage for certain wound-care supplies. Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 that is delivered, issued for delivery, renewed, amended or continued in this state on or after January 1, 2010, shall provide coverage for wound-care supplies that are medically necessary for the treatment of epidermolysis bullosa and are administered under the direction of a physician.

      (P.A. 09-51, S. 2.)

      History: P.A. 09-51 effective January 1, 2010.

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      Sec. 38a-530. Mandatory coverage for mammography and breast ultrasound. Breast density information included in mammography report. (a) Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state 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 policy shall provide additional benefits for comprehensive ultrasound screening of an entire breast or breasts if a mammogram demonstrates heterogeneous or dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology or if a woman is believed to be at increased risk for breast cancer due to family history or prior personal history of breast cancer, positive genetic testing or other indications as determined by a woman's physician or advanced practice registered nurse.

       (b) Benefits under this section shall be subject to any policy provisions that apply to other services covered by such policy.

       (c) On and after October 1, 2009, each mammography report provided to a patient shall include information about breast density, based on the Breast Imaging Reporting and Data System established by the American College of Radiology. Where applicable, such report shall include the following notice: "If your mammogram demonstrates that you have dense breast tissue, which could hide small abnormalities, you might benefit from supplementary screening tests, which can include a breast ultrasound screening or a breast MRI examination, or both, depending on your individual risk factors. A report of your mammography results, which contains information about your breast density, has been sent to your physician's office and you should contact your physician if you have any questions or concerns about this report.".

      (P.A. 90-243, S. 114; P.A. 01-171, S. 23; P.A. 05-69, S. 2; P.A. 06-38, S. 2; P.A. 09-41, S. 2.)

      History: P.A. 01-171 added "amended or continued" re policies in this state, substituted "October 1, 2001," for "October 1, 1988," re policy date, and consolidated Subdivs. (2) and (3) to provide annual coverage for any woman who is forty or over rather than coverage every two years for women 40 to 49 and annually thereafter; P.A. 05-69 added Subsec. designators (a) and (b), amended Subsec. (a) to require comprehensive ultrasound screening for certain women if recommended by a physician, and made technical changes in Subsec. (b); P.A. 06-38 amended Subsec. (a) to require policy to provide additional benefits for comprehensive ultrasound screening of an entire breast or breasts if mammogram demonstrates heterogeneous or dense breast tissue based on the BIRAD System or if a woman is believed to be at increased risk for breast cancer due to family history or prior personal history of breast cancer, positive genetic testing or other indications determined by a physician or advanced practice registered nurse, eliminating reference to screening recommended by a physician for a woman classified as a category 2, 3, 4 or 5 under such system; P.A. 09-41 added Subsec. (c) re breast density information required to be provided to a patient and notice where applicable.

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PART IV
COMPREHENSIVE HEALTH CARE PLANS

      Sec. 38a-554. (Formerly Sec. 38-374). Additional requirements and eligibility under group comprehensive health care plans. Coverage for stepchildren. Continuation of benefits under group plans. Insurance Commissioner's authority to coordinate benefits. A group comprehensive health care plan shall contain the minimum standard benefits prescribed in section 38a-553 and shall also conform in substance to the requirements of this section.

       (a) The plan shall be one under which the individuals eligible to be covered include: (1) Each eligible employee; (2) the spouse of each eligible employee, who shall be considered a dependent for the purposes of this section; and (3) unmarried children who are under twenty-six years of age. Each plan shall cover a stepchild on the same basis as a biological child.

       (b) The plan shall provide the option to continue coverage under each of the following circumstances until the individual is eligible for other group insurance, except as provided in subdivisions (3) and (4) of this subsection: (1) Notwithstanding any provision of this section, upon layoff, reduction of hours, leave of absence, or termination of employment, other than as a result of death of the employee or as a result of such employee's "gross misconduct" as that term is used in 29 USC 1163(2), continuation of coverage for such employee and such employee's covered dependents for the periods set forth for such event under federal extension requirements established by the federal Consolidated Omnibus Budget Reconciliation Act of 1985, P.L. 99-272, as amended from time to time, except that if such reduction of hours, leave of absence or termination of employment results from an employee's eligibility to receive Social Security income, continuation of coverage for such employee and such employee's covered dependents until midnight of the day preceding such person's eligibility for benefits under Title XVIII of the Social Security Act; (2) upon the death of the employee, continuation of coverage for the covered dependents of such employee for the periods set forth for such event under federal extension requirements established by the Consolidated Omnibus Budget Reconciliation Act of 1985, P.L. 99-272, as amended from time to time; (3) regardless of the employee's or dependent's eligibility for other group insurance, during an employee's absence due to illness or injury, continuation of coverage for such employee and such employee's covered dependents during continuance of such illness or injury or for up to twelve months from the beginning of such absence; (4) regardless of an individual's eligibility for other group insurance, upon termination of the group plan, coverage for covered individuals who were totally disabled on the date of termination shall be continued without premium payment during the continuance of such disability for a period of twelve calendar months following the calendar month in which the plan was terminated, provided claim is submitted for coverage within one year of the termination of the plan; (5) the coverage of any covered individual shall terminate: (A) As to a child, the plan shall provide the option for said child to continue coverage for the longer of the following periods: (i) At the end of the month following the month in which the child: Marries; ceases to be a resident of the state; becomes covered under a group health plan through the dependent's own employment; or attains the age of twenty-six. The residency requirement shall not apply to dependent children under nineteen years of age or full-time students attending an accredited institution of higher education. If on the date specified for termination of coverage on a child, the child is unmarried and incapable of self-sustaining employment by reason of mental or physical handicap and chiefly dependent upon the employee for support and maintenance, the coverage on such child shall continue while the plan remains in force and the child remains in such condition, provided proof of such handicap is received by the carrier within thirty-one days of the date on which the child's coverage would have terminated in the absence of such incapacity. The carrier may require subsequent proof of the child's continued incapacity and dependency but not more often than once a year thereafter, or (ii) for the periods set forth for such child under federal extension requirements established by the Consolidated Omnibus Budget Reconciliation Act of 1985, P.L. 99-272, as amended from time to time; (B) as to the employee's spouse, at the end of the month following the month in which a divorce, court-ordered annulment or legal separation is obtained, whichever is earlier, except that the plan shall provide the option for said spouse to continue coverage for the periods set forth for such events under federal extension requirements established by the Consolidated Omnibus Budget Reconciliation Act of 1985, P.L. 99-272, as amended from time to time; and (C) as to the employee or dependent who is sixty-five years of age or older, as of midnight of the day preceding such person's eligibility for benefits under Title XVIII of the federal Social Security Act; (6) as to any other event listed as a "qualifying event" in 29 USC 1163, as amended from time to time, continuation of coverage for such periods set forth for such event in 29 USC 1162, as amended from time to time, provided such plan may require the individual whose coverage is to be continued to pay up to the percentage of the applicable premium as specified for such event in 29 USC 1162, as amended from time to time. Any continuation of coverage required by this section except subdivision (4) or (6) of this subsection may be subject to the requirement, on the part of the individual whose coverage is to be continued, that such individual contribute that portion of the premium the individual would have been required to contribute had the employee remained an active covered employee, except that the individual may be required to pay up to one hundred two per cent of the entire premium at the group rate if coverage is continued in accordance with subdivision (1), (2) or (5) of this subsection. The employer shall not be legally obligated by sections 38a-505, 38a-546 and 38a-551 to 38a-559, inclusive, to pay such premium if not paid timely by the employee.

       (c) The commissioner shall adopt regulations, in accordance with chapter 54, concerning coordination of benefits between the plan and other health insurance plans. No individual or group health insurance plan shall coordinate benefits or otherwise reduce benefit payments because a person is covered by or receives benefits from a group specified disease policy delivered, issued for delivery, renewed, amended or continued in this state.

       (d) The plan shall make available to Connecticut residents, in addition to any other conversion privilege available, a conversion privilege under which coverage shall be available immediately upon termination of coverage under the group plan. The terms and benefits offered under the conversion benefits shall be at least equal to the terms and benefits of an individual comprehensive health care plan.

      (P.A. 75-616, S. 4, 12; P.A. 76-399, S. 1, 5; P.A. 86-106, S. 2; P.A. 87-274, S. 2; P.A. 97-268, S. 2; P.A. 02-55, S. 1; P.A. 03-77, S. 1; P.A. 07-185, S. 17; June Sp. Sess. P.A. 07-2, S. 65, 69; P.A. 08-147, S. 9; 08-181, S. 7; P.A. 09-124, S. 2.)

      History: P.A. 76-399 allowed continuation of coverage to the thirty-ninth week following date of eligibility loss, rather than the ninetieth day following such date in Subsec. (b)(1) and (2); P.A. 86-106 amended Subsec. (b) to provide that if a dependent child is suffering from any mental handicap, rather than only mental retardation, on the date his coverage would otherwise be terminated, the coverage may be continued, and to limit the termination of coverage of those eligible for Medicare to those persons who are 65 years of age or older; P.A. 87-274 amended Subsec. (b) to increase extension rights upon the loss of employment from 39 to 78 weeks, and upon the death of the employee from 39 to 156 weeks; Sec. 38-374 transferred to Sec. 38a-554 in 1991; P.A. 97-268 deleted reference to low, middle and high option deductibles, amended Subsec. (a)(2) to make spouse a dependent for purposes of section, amended Subsec. (b)(1) and (2) to add disqualification based on an employee's gross misconduct and to delete references to eligibility for periods of weeks and replace with references to federal COBRA, amended Subsec. (b)(5) to add choice for covered child by adding designators (i) and (ii) and allowing child and spouse to opt to continue coverage for periods provided under federal COBRA, and added court-ordered re annulment, added new Subdiv. (6) re other qualifying events, amended Subdiv. (7) to add reference to Subdiv. (6), to add reference to 102% of the entire premium and to add reference to Subdiv. (2) or (5) and made technical changes; P.A. 02-55 amended Subsec. (b)(3) to add "regardless of the employee's or dependent's eligibility for other group insurance" re an absence due to illness or injury, amended Subsec. (b)(4) to add "regardless of an individual's eligibility for other group insurance" re coverage for totally disabled individuals upon termination of the group plan, and made technical changes in Subsecs. (b) and (c); P.A. 03-77 amended Subsec. (b)(1) to add exception re continuation of coverage if reduction of hours, leave of absence or termination of employment results from eligibility to receive Social Security income; P.A. 07-185 amended Subsecs. (a) and (b) by making a child eligible for coverage under a parent's group comprehensive health care plan as long as the child remains unmarried and is under the age of 26 and residing in the state, effective July 1, 2007; June Sp. Sess. P.A. 07-2 changed effective date of P.A. 07-185, S. 17 to January 1, 2009, effective June 26, 2007, and made provisions allowing children to continue coverage until age 26 contingent upon children remaining state residents, except for full-time attendance at an out-of-state accredited institution of higher education or residency with a custodial parent pursuant to a child custody determination, effective January 1, 2009; P.A. 08-147 amended Subsec. (a) by deleting state residency requirement and amended Subsec. (b) by making technical changes and revising conditions upon which coverage of a child terminates by adding provision re coverage under a group health plan through a dependent child's own employment, deleting custodial parent provision, and specifying that dependent children to age 19 are exempt from state residency requirement, effective January 1, 2009; P.A. 08-181 amended Subsec. (c) by prohibiting coordination of benefits or reduction in benefit payments because a person is covered by or receives benefits from a group specified disease policy in this state, effective June 12, 2008; P.A. 09-124 added requirement that a stepchild be covered on the same basis as a biological child in Subsec. (a), effective June 18, 2009.

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