November 16, 2010 |
2010-R-0447 -Revised- | |
OLR BACKGROUNDER: STATE-MANDATED HEALTH INSURANCE BENEFITS — 2010 | ||
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By: Janet L. Kaminski Leduc, Senior Legislative Attorney |
A health insurance “mandate” is a requirement that an insurance company or health plan cover a specified benefit. In Connecticut, private health insurance benefit mandates are contained in Chapter 700c of the general statutes.
Each benefit mandate statute identifies the specific plans to which the mandate applies. Many of the mandates apply to both individual and group health insurance plans, including those insured plans issued to small employer groups. However, due to the federal Employee Retirement Income Security Act (ERISA) state benefit mandates generally do not apply to self-funded plans. For more information about this ERISA preemption, see OLR Research Report 2005-R-0753.
Table 1 lists and briefly describes Connecticut's mandated health insurance benefits. This report replaces an earlier report (2009-R-0317).
Since 2009, the legislature has mandated benefit coverage for four services:
1. autism spectrum disorders (PA 09-115),
2. epidermolysis bullosa (PA 09-51),
3. prescription eye drops (PA 09-136), and
4. oral chemotherapy (PA 10-63).
The first three mandates took effect on January 1, 2010. The last mandate takes effect on January 1, 2011.
Table 1: Connecticut's Mandated Health Insurance Benefits
Note: Some mandates require that services be “medically necessary.” State law specifies the definition of “medically necessary” that policies must include (see CGS §§ 38a-482a and 38a-513c).
Table 1: -Continued-
CGS § |
Mandate |
Group, Individual, or Both |
Description |
38a-489 38a-515 38a-554 |
Children - Mentally or Physically Handicapped |
Both |
After passing dependent status age and coverage would otherwise end, coverage must continue if child is both mentally or physically handicapped and dependent upon insured for support. |
38a-490 38a-508 38a-516 38a-549 |
Children - Newborns and Adopted |
Both |
Injury and sickness, including care and treatment of congenital defects and birth abnormalities, for newborns from birth and for adopted children from legal placement for adoption. |
38a-497 38a-554 |
Stepchildren |
Both |
Effective June 18, 2009, policies must cover stepchildren on the same basis as biological children. |
38a-490a 38a-516a |
Birth-to-Three |
Both |
At least $6,400 per child annually for medically necessary early invention services, up to $19,200 per child over three years. |
38a-490b 38a-516b |
Children's Hearing Aids |
Both |
Hearing aids for children age 12 and under. Coverage may be limited to $1,000 within a 24-month period. |
38a-490c 38a-516c |
Craniofacial Disorders |
Both |
Medically necessary orthodontic processes and appliances for treatment of craniofacial disorders for people age 18 or younger. Coverage is not required for cosmetic surgery. |
38a-492l 38a-516d |
Children with Cancer |
Both |
Coverage for children diagnosed with cancer after December 31, 1999 for neuropsychological testing a physician orders to assess the extent chemotherapy or radiation treatment has caused the child to have cognitive or developmental delays. Insurers cannot require pre-authorization for the tests. |
38a-491a 38a-517a |
Dental Coverage |
Both |
Medically necessary general anesthesia, nursing, and related hospital services for in-patient, outpatient, or one-day dental services. |
38a-492 38a-518 |
Accidental Ingestion or Consumption of Controlled Drugs |
Both |
Emergency medical care for the accidental ingestion or consumption of controlled drugs. Coverage is subject to a minimum of 30 days inpatient care and a maximum $500 for outpatient care per calendar year. |
38a-492a 38a-518a |
Hypodermic Needles and Syringes |
Both |
Hypodermic needles and syringes prescribed by a prescribing practitioner for administering medications. |
38a-492b 38a-518b |
Off-Label Cancer Drugs |
Both |
If a prescription drug is recognized for treatment of a specific type of cancer, a policy cannot exclude coverage of the drug when it is used for another type of cancer. |
38a-492c 38a-518c |
Protein Modified Food and Specialized Formula |
Both |
Amino acid modified and low protein modified food products when prescribed for the treatment of inherited metabolic diseases and cystic fibrosis. Medically necessary specialized formula for children up to age 12. Food and formula must be administered under the direction of a physician. Coverage for preparations, food products, and formulas must be on the same basis as coverage for outpatient prescription drugs. |
Table 1: -Continued-
CGS § |
Mandate |
Group, Individual, or Both |
Description |
38a-492d 38a-518d |
Diabetes |
Both |
Laboratory and diagnostic tests for all types of diabetes. Medically necessary equipment, drugs, and supplies for insulin-dependent, insulin using, gestational, and non-insulin using diabetes. |
38a-492e 38a-518e |
Diabetes Self-Management Training |
Both |
Outpatient self-management training prescribed by a licensed health care professional. Coverage is subject to the same terms and conditions as other policy benefits. |
38a-492f 38a-518f |
Prescription Drugs Removed from Formulary |
Both |
A prescription drug that has been removed from the list of covered drugs must be continued if the insured was previously using the drug for the treatment of a chronic illness and it is deemed medically necessary. |
38a-492g 38a-518g |
Prostate Screening |
Both |
Laboratory and diagnostic tests to screen for prostate cancer for men who are symptomatic, have a family history, or are over 50. |
38a-492h 38a-518h |
Lyme Disease Treatment |
Both |
Lyme disease treatment including not less than 30 days of intravenous antibiotic therapy, 60 days of oral antibiotic therapy, or both, and further treatment if recommended by a rheumatologist, infectious disease specialist, or neurologist. |
38a-492i 38a-518i |
Pain Management |
Both |
Access to a pain management specialist and coverage for pain treatment ordered by such specialist. |
38a-492j 38a-518j |
Ostomy Appliances and Supplies |
Both |
If policy covers ostomy surgery, policy must also cover up to $1000 per year for medically necessary ostomy-related appliances and supplies. |
38a-492k 38a-518k |
Colorectal Cancer Screening |
Both |
Colorectal cancer screening. Frequency of screening to be based on recommendations by the American College of Gastroenterology. |
38a-492m 38a-518l |
Prescription Eye Drops |
Both |
Effective January 1, 2010, policies that provide prescription eye drop coverage cannot deny coverage for prescription renewals when (1) the refill is requested by the insured person less than 30 days from either (a) the date the original prescription was given to the insured or (b) the last date the prescription refill was given to the insured, whichever is later, and (2) the prescribing physician indicates on the original prescription that additional quantities are needed and the refill request does not exceed this amount. |
38a-492n 38a-518m |
Epidermolysis Bullosa |
Both |
Effective January 1, 2010, policies must cover wound care supplies that are medically necessary to treat epidermolysis bullosa (a rare skin disorder) and administered under a physician's direction. |
38a-493 38a-520 |
Home Health Care |
Both |
Home health care, including (1) part-time or intermittent nursing care and home health aide services; (2) physical, occupational, or speech therapy; (3) medical supplies, drugs and medicines; and (4) medical social services. Coverage can be limited to no less than 80 visits per year and, for a terminally ill person, no more than $200 for medical social services. Coverage can be subject to an annual deductible of up to $50 and a coinsurance of no less than 75%, except that a high deductible plan used to establish a medical savings account is exempt from the deductible limit. |
38a-523 |
Comprehensive Rehabilitation Services |
Group |
Group health insurance must offer coverage for comprehensive rehabilitation services, including (1) physician services, physical and occupational therapy, nursing care, psychological and audiological services, and speech therapy; (2) social services provided by a social worker; (3) respiratory therapy; (4) prescription drugs and medicines; (5) prosthetic and orthotic devices and; (6) other supplies and services prescribed by a doctor. |
Table 1: -Continued-
CGS § |
Mandate |
Group, Individual, or Both |
Description |
38a-496 38a-524 |
Occupational Therapy |
Both |
If policy covers physical therapy, it must provide coverage for occupational therapy. |
38a-498 38a-525 |
Ambulance Services |
Both |
Ambulance service when medically necessary. Payment must be on a direct pay basis where notice of assignment is reflected on the bill. |
38a-498a 38a-525a |
911 Calls |
Both |
Cannot require preauthorization for 911 calls. |
38a-498b 38a-525b |
Mobile Field Hospitals |
Both |
Benefits for isolation care and emergency services provided by mobile field hospitals, previously called critical access hospitals. Such benefits are subject to any policy provisions that apply to other covered services. The rates a policy pays must be equal to the rates Medicaid pays, as determined by the Department of Social Services. |
38a-498c 38a-525c |
Injured and Under the Influence |
Both |
Insurance polices prohibited from denying coverage for health care services rendered to an injured insured person if the injury is alleged to have occurred or occurs when the person has an elevated blood alcohol level (0.08% or more) or is under the influence of drugs or alcohol. 38a-501 Long-Term Care Policy – |
38a-501 |
Long-Term Care Policy – Elimination Period |
Individual |
Requires an elimination period (i.e., a waiting period after the onset of the injury, illness, or function loss during which no benefits are payable) that is (1) up to 100 days of confinement or (2) between 100 days and two years of confinement if an irrevocable trust is in place that is estimated to be sufficient to cover the person's confinement costs during this period. Sets requirements for the trust. |
38a-503 38a-530 |
Mammography and Breast Cancer Screening |
Both |
Baseline mammogram for woman 35 to 39 and one every year for woman 40 and older. Additional coverage must be provided for a comprehensive ultrasound screening of a woman's entire breast(s) if (1) a mammogram shows heterogeneous or dense breast tissue based on BI-RADS or (2) the woman is at increased breast cancer risk because of family history, her prior history, genetic testing, or other indications determined by her physician or advanced-practice nurse. Coverage is subject to any policy provisions applicable to other covered services. |
38a-503b 38a-530b |
Obstetrician-Gynecologist; Pap Smear |
Both |
Direct access to participating in-network ob-gyn for gynecological examination, pregnancy care, and primary and preventive obstetric and gynecologic services required as result of a gynecological examination or condition (includes pap smear). Female enrollees may also designate participating ob-gyn or other doctor as primary care provider. 38a-503c |
38a-503d 38a-530d |
Mastectomy |
Both |
Minimum 48-hour hospital stay after mastectomy or lymph node dissection or longer stay if recommended by physician. |
38a-503e 38a-530e |
Contraceptives |
Both |
If prescription drugs are covered, prescription contraceptives must be covered. An employer or individual may decline contraceptive coverage if it conflicts with religious beliefs. |
Table 1: -Continued-
CGS § |
Mandate |
Group, Individual, or Both |
Description |
38a-533 |
Alcoholism |
Group |
Expenses incurred in connection with medical complications of alcoholism such as cirrhosis of the liver, gastrointestinal bleeding, pneumonia, and delirium tremens. |
38a-507 38a-534 |
Chiropractic Services |
Both |
Cover chiropractor services to same extent as coverage for a physician. |
38a-535 |
Preventive Pediatric Care |
Group |
Preventive pediatric care at the following intervals (1) every 2 months from birth to 6 months, (2) every 3 months from 9 to 18 months, and (3) annually from 2 to 6 years of age. Coverage is subject to any policy provisions that apply to other services covered under the policy. |
38a-535 |
Lead Screening |
Both |
Coverage for blood lead screening and risk assessments ordered by primary care providers in accordance with the law. |
38a-509 38a-536 |
Infertility |
Both |
Medically necessary costs of diagnosing and treating infertility. |
38a-542(a)&(b) |
Breast Implant Removal |
Group |
Medically necessary removal of breast implants implanted on or before July 1, 1994. Annual coverage must be at least $1,000. |
38a-504(a)&(b) 38a-542(a)&(b) |
Treatment for Leukemia, Tumors, and Wigs for Chemotherapy Patients |
Both |
Surgical removal of tumors and treatment of leukemia, including outpatient chemotherapy, reconstructive surgery, non-dental prosthesis, surgical removal of breasts due to tumors, and a wig if prescribed by a licensed oncologist for a patient suffering hair loss from chemotherapy. Annual coverage must be at least $500 for surgical tumor removal, $500 for reconstructive surgery, $500 for outpatient chemotherapy, $350 for a wig, and $300 for prosthesis, except for surgical removal of breasts due to tumors, the prosthesis benefit must be at least $300 for each breast removed. |
38a-504(c) 38a-542(c) |
Breast Reconstruction after Mastectomy |
Both |
Reconstructive surgery on non-diseased breast for symmetrical appearance. Coverage is subject to the same terms and conditions as other benefits under the policy. |
38a-504a – 38a-504g; 38a-542a – 38a-542g |
Cancer Clinical Trials |
Both |
Routine patient costs relating to cancer clinical trials. Out-of-network hospitalization paid as in-network benefit if services are not available in network. Such trials must have peer-reviewed protocols approved by one of several federal organizations. |
38a-511 38a-550 |
Copays for Imaging Services (MRIs, CAT scans, and PET scans) |
Both |
Limits copays for MRIs and CAT scans to (1) $375 for all such services annually and (2) $75 for each one. Limits copays for PET scans to (1) $400 for all such scans annually and (2) $100 for each one. Limits not applicable (1) if the ordering physician performs the service or is in the same practice group as the one who does and (2) to high deductible health plans designed to be compatible with federally qualified Health Savings Accounts. |
PA 10-63 |
Oral Chemotherapy |
Both |
Effective January 1, 2011, policies that cover intravenously and orally administered anticancer medications must cover the orally administered medication on at least as favorable a basis as the intravenously administered medication. |
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