Chapter 700c

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; (16) single service ancillary health coverage, including, but not limited to, dental, vision or prescription drug coverage; and (17) short-term care 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; P.A. 16-63, S. 1.)

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; P.A. 16-63 added Subdiv. (17) re short-term care coverage and made a technical change.

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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 service corporation, medical service corporation, health care center or employee welfare benefit plan that 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 an administrative law judge less attorneys' fees approved by the district administrative law judge 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 administrative law judge 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 administrative law judge, 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 service corporation, 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 service corporation, 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; P.A. 15-118, S. 1, 2; P.A. 21-18, S. 1.)

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; P.A. 15-118 made technical changes in Subsecs. (b) and (e); pursuant to P.A. 21-18, “workers' compensation commissioner” and “commissioner” were changed editorially by the Revisors to “administrative law judge” in Subsecs. (b), (c) and (d), effective October 1, 2021.

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

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

Annotations to former section 38-174n:

Cited. 216 C. 815.

Cited. 22 CA 27; judgment reversed, see 217 C. 631; Id., 539; judgment reversed, see 219 C. 439.

Annotations to present section:

Cited. 217 C. 631; 219 C. 439.

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Sec. 38a-471. (Formerly Sec. 38-174o). Third party prescription programs. Notice of cancellation. Applicability of section. (a) As used in this section, a “third party prescription program” means a system of providing for reimbursement for the cost of drugs or pharmaceutical services under a contractual arrangement or agreement with a provider of such drugs or services. Such programs shall include, but not be limited to, employee benefit plans under which a consumer receives prescription drugs or pharmaceutical services and such drugs or services are paid for in part by an agent of the consumer's employer or others. An “administrator” means the program administrator of a third party prescription program.

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

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

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

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

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

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

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

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

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

(P.A. 81-455, S. 1–8.)

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

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

(b) Whenever there is in existence a contract by an insurer for payment to, or on behalf of, an applicant or recipient of medical assistance under the Medicaid program under said contract on account of bills incurred by the applicant or recipient for medical services, including, but not limited to, physician services, nursing services, pharmaceutical services, surgical care and hospital care, the assignment of the benefits of the contract by such applicant or recipient or his legally liable relative pursuant to section 17b-265 shall, upon receipt of notice from the assignee, be authority for payment by the insurer directly to the assignee. If notice is provided by the assignee to the insurer in accordance with the provisions of section 17b-265, the insurer shall be liable to the assignee for any amount payable to the assignee under the contract.

(c) No insurer, health care center or issuer of any service plan contract for hospital or medical expense coverage delivered, issued for delivery or renewed in this state shall impose requirements on the Department of Social Services that have the effect of denying or limiting benefits that have been assigned pursuant to this section. The assignment of benefits shall be in accordance with the provisions of this section.

(1961, P.A. 124; P.A. 75-591; P.A. 90-243, S. 70; 90-283, S. 2; May Sp. Sess. P.A. 94-5, S. 8, 30; June 18 Sp. Sess. P.A. 97-2, S. 101, 165; P.A. 04-76, S. 36; P.A. 11-44, S. 136; P.A. 15-118, S. 43; P.A. 17-15, S. 36.)

History: P.A. 75-591 clarified existing provision by substituting “sent by registered or certified mail” for “lodged with”, authorized assignment of benefits to department heads, required a copy to be sent to insured and added provision re state's lien on contracts for care rendered by state hospitals, institutions, etc.; P.A. 90-243 made technical changes for statutory consistency; P.A. 90-283 added Subsec. (b) re assignment of benefits of contract by an applicant or recipient of medical assistance; Sec. 38-174a transferred to Sec. 38a-472 in 1991; May Sp. Sess. P.A. 94-5 added a new Subsec. (c) to prevent insurers from imposing requirements on the department of social services which deny or limit benefits assigned pursuant to this section, effective July 1, 1994; June 18 Sp. Sess. P.A. 97-2 amended Subsec. (b) to make technical and conforming changes to references re assistance programs, effective July 1, 1997; P.A. 04-76 amended Subsec. (b) by deleting reference to “general assistance program”; P.A. 11-44 amended Subsec. (b) by deleting “the state-administered general assistance program or”, effective July 1, 2011; P.A. 15-118 made technical changes in Subsec. (c); P.A. 17-15 made technical changes in Subsec. (a).

Cited. 219 C. 439.

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Sec. 38a-472a. Medical provider indemnification agreements prohibited. No contract between a managed care company, other organization or insurer authorized to do business in this state and a medical provider practicing in this state for the provision of services may require that the medical provider indemnify the managed care company, other organization or insurer for any expenses and liabilities including, without limitation, judgments, settlements, attorneys' fees, court costs and any associated charges incurred in connection with any claim or action brought against a managed care company, other organization or insurer on the basis of its determination of medical necessity or appropriateness of health care services if the information provided by such medical provider used in making the determination was accurate and appropriate at the time it was given. As used in this section and section 38a-472b, “medical provider” means any person licensed pursuant to chapters 370 to 373, inclusive, or chapter 375, 378, 379, 380 or 383.

(P.A. 95-199, S. 3; P.A. 15-118, S. 44; P.A. 19-98, S. 7.)

History: P.A. 15-118 made a technical change; P.A. 19-98 redefined “medical provider” by adding reference to Ch. 378.

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

(P.A. 95-199, S. 4.)

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

(b) No person that issues a policy described in subsection (a) of this section that uses a provider network for such policy shall materially adjust the fee schedule for in-network providers more than once annually.

(c) Each person that makes a material adjustment described in subsection (b) of this section shall issue a notice to each in-network provider at least ninety days before the effective date of such adjustment. Each such notice shall be sent by mail, electronic mail or facsimile, and disclose:

(1) The percentage effect that such adjustment will have on such provider's fees; or

(2) A measure, other than the measure described in subdivision (1) of this subsection, that will enable such provider to understand how such adjustment will affect such provider's fees for the twenty covered procedures that such provider most frequently performed, and for which such provider sought reimbursement, during the twelve months immediately preceding the date of such notice.

(P.A. 04-125, S. 1; P.A. 11-19, S. 7; P.A. 19-155, S. 3.)

History: P.A. 11-9 made a technical change; P.A. 19-155 designated existing provisions re policy that provides coverage for inpatient or outpatient dental services only as Subsec. (a) and added Subsecs. (b) and (c) re material adjustments to fee schedules for in-network providers, effective January 1, 2020.

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Sec. 38a-472d. Public education outreach program re health insurance availability and eligibility requirements. (a) Not later than January 1, 2006, the Insurance Commissioner, in consultation with the Commissioner of Social Services and the Healthcare Advocate, shall develop a comprehensive public education outreach program to educate health insurance consumers about the availability and general eligibility requirements of various health insurance options in this state. The program shall maximize public information concerning health insurance options in this state and shall provide for the dissemination of such information on the Insurance Department's Internet web site.

(b) The information on the department's Internet web site shall reference the availability and general eligibility requirements of (1) programs administered by the Department of Social Services, including, but not limited to, the Medicaid program and HUSKY A and B, (2) health insurance coverage provided by the Comptroller under subsection (i) of section 5-259, and (3) other health insurance coverage offered through local, state or federal agencies or through entities licensed in this state. The commissioner shall update the information on the web site at least quarterly.

(P.A. 05-253, S. 1; P.A. 11-44, S. 137; P.A. 15-69, S. 39; 15-247, S. 35.)

History: P.A. 11-44 amended Subsec. (b)(1) by deleting “the state-administered general assistance program” and making technical changes, effective July 1, 2011; P.A. 15-69 amended Subsec. (b)(1) to replace “the HUSKY Plan, Part A and Part B” with “HUSKY A and B”, effective June 19, 2015; P.A. 15-247 amended Subsec. (b) by deleting former Subdiv. (3) re health insurance coverage available under comprehensive health care plans and redesignating existing Subdiv. (4) as Subdiv. (3), effective July 10, 2015.

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Sec. 38a-472e. Health insurer. Requirements re offer to contract with a school-based health center. Each health insurer licensed to do business in this state shall, at the request of any school-based health center or group of school-based health centers, offer to contract with such center or centers to provide reimbursement for covered health care services to persons who are insured by such licensed insurer. Such offer shall be made on terms and conditions similar to contracts offered to other providers of health care services.

(P.A. 10-118, S. 1.)

History: P.A. 10-118 effective June 7, 2010.

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Sec. 38a-472f. Network adequacy. Health carrier duties and responsibilities. Access plan filing. (a) As used in this section:

(1) “Authorized representative” means (A) an individual to whom a covered person has given express written consent to represent the covered person, (B) an individual authorized by law to provide substituted consent for a covered person, or (C) the covered person's treating health care provider when the covered person is unable to provide consent or a family member of the covered person;

(2) “Covered benefit” or “benefit” means those health care services to which a covered person is entitled under the terms of a health benefit plan;

(3) “Covered person” has the same meaning as provided in section 38a-591a;

(4) “Essential community provider” means a health care provider or facility that (A) serves predominantly low-income, medically underserved individuals and includes covered entities, as defined in 42 USC 256b, as amended from time to time, or (B) is described in 42 USC 1396r-8(c)(1)(D)(i)(IV), as amended from time to time;

(5) “Facility” has the same meaning as provided in section 38a-591a;

(6) (A) “Health benefit plan” means an insurance policy or contract, certificate or agreement offered, delivered, issued for delivery, renewed, amended or continued in this state to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services;

(B) “Health benefit plan” does not include:

(i) Coverage of the type specified in subdivisions (5) to (9), inclusive, (14) and (15) of section 38a-469 or any combination thereof;

(ii) Coverage issued as a supplement to liability insurance;

(iii) Liability insurance, including general liability insurance and automobile liability insurance;

(iv) Workers' compensation insurance;

(v) Automobile medical payment insurance;

(vi) Credit insurance;

(vii) Coverage for on-site medical clinics;

(viii) Other insurance coverage similar to the coverages specified in subparagraphs (B)(ii) to (B)(vii), inclusive, of this subdivision that are specified in regulations issued pursuant to the Health Insurance Portability and Accountability Act of 1996, P.L. 104-191, as amended from time to time, under which benefits for health care services are secondary or incidental to other insurance benefits;

(ix) (I) Benefits for long-term care, nursing home care, home health care, community-based care or any combination thereof, or (II) other similar, limited benefits that are specified in regulations issued pursuant to the Health Insurance Portability and Accountability Act of 1996, P.L. 104-191, as amended from time to time, provided any benefits specified in subparagraphs (B)(ix)(I) and (B)(ix)(II) of this subdivision are provided under a separate insurance policy, certificate or contract and are not otherwise an integral part of a health benefit plan; or

(x) Coverage of the type specified in subdivisions (3) and (13) of section 38a-469 or other fixed indemnity insurance if (I) such coverage is provided under a separate insurance policy, certificate or contract, (II) there is no coordination between the provision of the benefits and any exclusion of benefits under any group health plan maintained by the same plan sponsor, and (III) the benefits are paid with respect to an event without regard to whether benefits were also provided under any group health plan maintained by the same plan sponsor;

(7) “Health care provider” has the same meaning as provided in section 38a-477aa;

(8) “Health care services” has the same meaning as provided in section 38a-478;

(9) “Health carrier” has the same meaning as provided in section 38a-591a;

(10) “Intermediary” means a person, as defined in section 38a-1, authorized to negotiate and execute health care provider contracts with health carriers on behalf of health care providers or a network;

(11) “Network” means the group or groups of participating providers providing health care services under a network plan;

(12) “Network plan” means a health benefit plan that requires a covered person to use, or creates incentives, including financial incentives, for a covered person to use, health care providers or facilities that are managed, owned, under contract with or employed by the health carrier;

(13) “Participating provider” means a health care provider or a facility that, under a contract with a health carrier or such health carrier's contractor or subcontractor, has agreed to provide health care services to such health carrier's covered persons, with an expectation of receiving payment or reimbursement directly or indirectly from the health carrier, other than coinsurance, copayments or deductibles;

(14) “Primary care” means health care services for a range of common physical, mental or behavioral health conditions, provided by a health care provider;

(15) “Primary care provider” means a participating health care provider designated by a health carrier to supervise, coordinate or provide initial health care services or continuing health care services to a covered person, and who may be required by the health carrier to initiate a referral for specialty care and maintain supervision of health care services provided to the covered person;

(16) “Specialist” means a health care provider who (A) focuses on a specific area of physical, mental or behavioral health or a specific group of patients, and (B) has successfully completed required training and is recognized by this state to provide specialty care. “Specialist” includes a subspecialist who has additional training and recognition beyond that required for a specialist;

(17) “Specialty care” means advanced medically necessary care and treatment of specific physical, mental or behavioral health conditions, or those conditions that may manifest in particular ages or subpopulations, that are provided by a specialist in coordination with a health care provider; and

(18) “Tiered network” means a network that identifies and groups some or all types of health care providers and facilities into specific groups to which different participating provider reimbursement, covered person cost-sharing or participating provider access requirements, or any combination thereof, apply for the same health care services.

(b) The provisions of this section and sections 38a-477g and 38a-477h shall apply to all health carriers that deliver, issue for delivery, renew, amend or continue a network plan in this state.

(c) (1) (A) Each health carrier shall establish and maintain a network that includes a sufficient number and appropriate types of participating providers, including those that serve predominantly low-income, medically underserved individuals, to assure that all covered benefits will be accessible to all such health carrier's covered persons without unreasonable travel or delay.

(B) Covered persons shall have access to emergency services and, to the extent urgent crisis center services are available, urgent crisis center services, twenty-four hours a day, seven days a week. For the purposes of this subparagraph, “emergency services” and “urgent crisis center services” have the same meanings as provided in section 38a-477aa.

(2) The Insurance Commissioner shall determine the sufficiency of a health carrier's network in accordance with the provisions of this subsection and may establish sufficiency by reference to any reasonable criteria, including, but not limited to, (A) the ratio of participating providers to covered persons by specialty, (B) the ratio of primary care providers to covered persons, (C) the geographic accessibility of participating providers, (D) the geographic variation and dispersion of the state's population, (E) the wait times for appointments with participating providers, (F) the hours of operation of participating providers, (G) the ability of the network to meet the needs of covered persons that may include low-income individuals, children and adults with serious, chronic or complex conditions or physical or mental disabilities or individuals with limited English proficiency, (H) the availability of other health care delivery system options, such as centers of excellence and mobile clinics, (I) the volume of technological and specialty care services available to serve the needs of covered persons who require technologically advanced or specialty care services, (J) the extent to which participating health care providers are accepting new patients, (K) the degree to which (i) participating health care providers are authorized to admit patients to hospitals participating in the network, and (ii) hospital-based health care providers are participating providers, and (L) the regionalization of specialty care.

(d) (1) Each health carrier shall establish and maintain a process to ensure that a covered person receives a covered benefit at an in-network level, including an in-network level of cost-sharing, from a nonparticipating provider, or shall make other arrangements acceptable to the commissioner, when:

(A) The health carrier has a sufficient network but does not have (i) a type of participating provider available to provide the covered benefit to the covered person, or (ii) a participating provider available to provide the covered benefit to the covered person without unreasonable travel or delay; or

(B) The health carrier has an insufficient number or type of participating providers available to provide the covered benefit to the covered person without unreasonable travel or delay.

(2) Each health carrier shall disclose to a covered person the process to request a covered benefit from a nonparticipating provider, as provided under subdivision (1) of this subsection, when:

(A) The covered person is diagnosed with a condition or disease that requires specialty care; and

(B) The health carrier (i) does not have a participating provider of the required specialty with the professional training and expertise to treat or provide health care services for the condition or disease, or (ii) cannot provide reasonable access to a participating provider of the required specialty with the professional training and expertise to treat or provide health care services for the condition or disease without unreasonable travel or delay.

(3) The health carrier shall deem the health care services such covered person receives from a nonparticipating provider pursuant to subdivision (2) of this subsection to be health care services provided by a participating provider, including counting the covered person's cost-sharing for such health care services toward the maximum out-of-pocket expenses limit applicable to health care services received from participating providers under the health benefit plan.

(4) The health carrier shall ensure that the processes described under subdivisions (1) and (2) of this subsection address a covered person's request to obtain a covered benefit from a nonparticipating provider in a timely fashion appropriate to the covered person's condition. The time frames for such processes shall mirror those set forth in subsections (e) and (f) of section 38a-591g for external reviews of adverse determinations and final adverse determinations.

(5) The health carrier shall document all requests from its covered persons to obtain a covered benefit from a nonparticipating provider pursuant to this subsection and shall provide such documentation to the commissioner upon request.

(6) No health carrier shall use the process described in subdivisions (1) and (2) of this subsection as a substitute for establishing and maintaining a sufficient network as required under subsection (b) of this section. No covered person shall use such process to circumvent the use of covered benefits available through a health carrier's network delivery system options.

(7) Nothing in this subsection shall be construed to affect any rights or remedies available to a covered person under sections 38a-591a to 38a-591g, inclusive, or federal law relating to internal or external claims grievance and appeals processes.

(e) (1) Each health carrier shall:

(A) Maintain adequate arrangements to assure that such health carrier's covered persons have reasonable access to participating providers located near such covered persons' places of residence or employment. In determining whether a health carrier has complied with this subparagraph, the commissioner shall give due consideration to the availability of health care providers with the requisite expertise and training in the service area under consideration;

(B) Monitor on an ongoing basis the ability, clinical capacity and legal authority of its participating providers to provide all covered benefits to its covered persons;

(C) Establish and maintain procedures by which a participating provider will be notified on an ongoing basis of the specific covered health care services for which such participating provider will be responsible, including any limitations on or conditions of such services;

(D) Notify participating providers of their obligations, if any, (i) to collect applicable coinsurance, deductibles or copayments from covered persons pursuant to a covered person's health benefit plan, and (ii) to notify covered persons, prior to delivery of health care services if possible, of such covered persons' financial obligations for noncovered benefits;

(E) Establish and maintain procedures by which a participating provider may determine in a timely manner at the time benefits are provided whether an individual is a covered person or is within a grace period for payment of premium during which such health carrier may hold a claim for health care services pending receipt of payment of premium by such health carrier;

(F) Timely notify a health care provider or facility, when such health carrier has included such health care provider or facility as a participating provider for any of such health carrier's health benefit plans, of such health care provider's or facility's network participation status;

(G) Notify participating providers of the participating provider's responsibilities with respect to such health carrier's applicable administrative policies and programs, including, but not limited to, payment terms, utilization review, quality assessment and improvement programs, credentialing, grievance and appeals processes, date reporting requirements, reporting requirements for timely notice of changes in practice such as discontinuance of accepting new patients, confidentiality requirements, any applicable federal or state programs and obtaining necessary approval of referrals to nonparticipating providers; and

(H) Establish and maintain procedures for the resolution of administrative, payment or other disputes between the health carrier and a participating provider.

(2) No health carrier shall:

(A) Offer or provide an inducement to a participating provider that would encourage or otherwise incentivize a participating provider to provide less than medically necessary health care services to a covered person;

(B) Prohibit a participating provider from (i) discussing any specific or all treatment options with covered persons, irrespective of such health carrier's position on such treatment options, or (ii) advocating on behalf of covered persons within the utilization review or grievance and appeals processes established by such health carrier or a person contracting with such health carrier or in accordance with any rights or remedies available to covered persons under sections 38a-591a to 38a-591g, inclusive, or federal law relating to internal or external claims grievance and appeals processes; or

(C) Penalize a participating provider because such participating provider reports in good faith to state or federal authorities any act or practice by such health carrier that jeopardizes patient health or welfare.

(f) (1) Each health carrier shall develop standards, to be used by such health carrier and its intermediaries, for selecting and tiering, as applicable, participating providers and each health care provider specialty.

(2) No health carrier shall establish selection or tiering criteria in a manner that would (A) allow the health carrier to discriminate against high-risk populations by excluding or tiering participating providers because they are located in a geographic area that contains populations or participating providers that present a risk of higher-than-average claims, losses or health care services utilization, or (B) exclude participating providers because they treat or specialize in treating populations that present a risk of higher-than-average claims, losses or health care services utilization. Nothing in this subdivision shall be construed to prohibit a health carrier from declining to select a health care provider or facility for participation in such health carrier's network who fails to meet legitimate selection criteria established by such health carrier.

(3) No health carrier shall establish selection criteria that would allow the health carrier to discriminate, with respect to participation in a network plan, against any health care provider who is acting within the scope of such health care provider's license or certification under state law. Nothing in this subdivision shall be construed to require a health carrier to contract with any health care provider or facility willing to abide by the terms and conditions for participation established by such health carrier.

(4) Each health carrier shall make the standards required under subdivision (1) of this subsection available to the commissioner for review and shall post on its Internet web site and make available to the public a plain language description of such standards.

(5) Nothing in this subsection shall require a health carrier, its intermediaries or health care provider networks with which such health carrier or intermediary contracts to (A) employ specific health care providers acting within the scope of such health care providers' license or certification under state law who meet such health carrier's selection criteria, or (B) contract with or retain more health care providers acting within the scope of such health care providers' license or certification under state law than are necessary to maintain a sufficient network.

(g) (1) (A) A health carrier and participating provider shall provide at least ninety days' written notice to each other before the health carrier removes a participating provider from the network or the participating provider leaves the network. Each participating provider that receives a notice of removal or issues a departure notice shall provide to the health carrier a list of such participating provider's patients who are covered persons under a network plan of such health carrier.

(B) A health carrier shall make a good faith effort to provide written notice, not later than thirty days after the health carrier receives or issues a written notice under subparagraph (A) of this subdivision, to all covered persons who are patients being treated on a regular basis by or at the participating provider being removed from or leaving the network, irrespective of whether such removal or departure is for cause.

(C) For each contract entered into, renewed, amended or continued on or after July 1, 2018, between a health carrier and a participating provider that is a hospital, as defined in section 38a-493, or a parent corporation of a hospital, if the contract is not renewed or is terminated by either the health carrier or the participating provider, the health carrier and the participating provider shall continue to abide by the terms of such contract, including reimbursement terms, for a period of sixty days from the date of termination or, in the case of a nonrenewal, from the end of the contract period. Except as otherwise agreed between such health carrier and such participating provider, the reimbursement terms of any contract entered into by such health carrier and such participating provider during said sixty-day period shall be retroactive to the date of termination or, in the case of a nonrenewal, the end date of the contract period. This subparagraph shall not apply if the health carrier and participating provider agree, in writing, to the termination or nonrenewal of the contract and the health carrier and participating provider provide the notices required under subparagraphs (A) and (B) of this subdivision.

(2) (A) For the purposes of this subdivision:

(i) “Active course of treatment” means (I) a medically necessary, ongoing course of treatment for a life-threatening condition, (II) a medically necessary, ongoing course of treatment for a serious condition, (III) medically necessary care provided during the second or third trimester of pregnancy, or (IV) a medically necessary, ongoing course of treatment for a condition for which a treating health care provider attests that discontinuing care by such health care provider would worsen the covered person's condition or interfere with anticipated outcomes;

(ii) “Life-threatening condition” means a disease or condition for which the likelihood of death is probable unless the course of such disease or condition is interrupted;

(iii) “Serious condition” means a disease or condition that requires complex ongoing care such as chemotherapy, radiation therapy or postoperative visits, which the covered person is currently receiving; and

(iv) “Treating provider” means a covered person's treating health care provider or a facility at which a covered person is receiving treatment, that is removed from or leaves a health carrier's network pursuant to subdivision (1) of this subsection.

(B) (i) Each health carrier shall establish and maintain reasonable procedures to transition a covered person, who is in an active course of treatment with a participating health care provider or at a participating facility that becomes a treating provider, to another participating provider in a manner that provides for continuity of care.

(ii) In addition to the notice required under subparagraph (B) of subdivision (1) of this subsection, the health carrier shall provide to such covered person (I) a list of available participating providers in the same geographic area as such covered person who are of the same health care provider or facility type, and (II) the procedures for how such covered person may request continuity of care as set forth in this subparagraph.

(iii) Such procedures shall provide that:

(I) Any request for a continuity of care period shall be made by the covered person or the covered person's authorized representative;

(II) A request for a continuity of care period, made by a covered person who meets the requirements under subparagraph (B)(i) of this subdivision or such covered person's authorized representative and whose treating provider was not removed from or did not leave the network for cause, shall be reviewed by the health carrier's medical director after consultation with such treating provider; and

(III) For a covered person who is in the second or third trimester of pregnancy, the continuity of care period shall extend through the postpartum period.

(iv) The continuity of care period for a covered person who is undergoing an active course of treatment shall extend to the earliest of the following: (I) Termination of the course of treatment by the covered person or the treating provider; (II) ninety days after the date the participating provider is removed from or leaves the network, unless the health carrier's medical director determines that a longer period is necessary; (III) the date that care is successfully transitioned to another participating provider; (IV) the date benefit limitations under the health benefit plan are met or exceeded; or (V) the date the health carrier determines care is no longer medically necessary.

(v) The health carrier shall only grant a continuity of care period as provided under subparagraph (B)(iv) of this subdivision if the treating provider agrees, in writing, (I) to accept the same payment from such health carrier and abide by the same terms and conditions as provided in the contract between such health carrier and treating provider when such treating provider was a participating provider, and (II) not to seek any payment from the covered person for any amount for which such covered person would not have been responsible if the treating provider was still a participating provider.

(h) (1) (A) Beginning January 1, 2017, a health carrier shall file with the commissioner for review each existing network as of said date and an access plan for each such network.

(B) For each new network a health carrier intends to offer after January 1, 2017, such health carrier shall file with the commissioner for review, within thirty days prior to the date such health carrier will offer such new network, the new network and an access plan for such new network.

(C) A health carrier shall notify the commissioner of any material change to an existing network not later than fifteen business days after such change and shall file with the commissioner an update to such existing network not later than thirty days after such material change. For the purposes of this subparagraph, “material change” means (i) a change of twenty-five per cent or more in the participating providers in a health carrier's network or the type of participating providers available in a health carrier's network to provide health care services or specialty care to covered persons, or (ii) any change that renders a health carrier's network noncompliant with one or more network adequacy standards, including, but not limited to, (I) a significant reduction in the number of primary care or specialty care providers available in the network, (II) a reduction in a specific type of participating provider such that a specific covered benefit is no longer available to covered persons, (III) a change to a tiered, multitiered, layered or multilevel network plan structure, (IV) a change in inclusion of a major health system, as defined in section 19a-508c, that causes a network to be significantly different from what a covered person initially purchased, or (V) after notice, any other change the commissioner deems to be a material change.

(2) Each access plan required under subdivision (1) of this subsection shall be in a form and manner prescribed by the commissioner and shall contain descriptions of at least the following:

(A) The health carrier's procedures for making and authorizing referrals within and outside its network, if applicable;

(B) The health carrier's procedures for monitoring and assuring on an ongoing basis the sufficiency of its network to meet the health care needs of the populations that enroll in its network plans;

(C) The factors used by the health carrier to build its network, including a description of the network and the criteria used to select and tier health care providers and facilities;

(D) The health carrier's efforts to address the needs of covered persons, including, but not limited to, children and adults, including those with limited English proficiency or illiteracy, diverse cultural or ethnic backgrounds, physical or mental disabilities and serious, chronic or complex conditions. Such description shall include the health carrier's efforts, when appropriate, to include various types of essential community providers in its network;

(E) The health carrier's methods for assessing the health care needs of covered persons and covered persons' satisfaction with the health care services provided;

(F) The health carrier's method of informing covered persons of the network plan's covered benefits, including, but not limited to, (i) the network plan's grievance and appeals processes, (ii) the network plan's process for covered persons to choose or change participating providers in the network plan, (iii) the health carrier's process for updating its participating provider directories for each of its network plans, (iv) a statement of the health care services offered by the network plan, including those health care services offered through the preventive care benefit, if applicable, and (v) the network plan's procedures for covering and approving emergency, urgent and specialty care, if applicable;

(G) The health carrier's system for ensuring the coordination and continuity of care for covered persons (i) referred to specialty physicians, or (ii) using ancillary services that are covered benefits, including, but not limited to, social services and other community resources and for ensuring appropriate discharge planning for covered persons using such ancillary services;

(H) The health carrier's process for enabling covered persons to change their designation of a primary care provider, if applicable;

(I) The health carrier's proposed plan for providing continuity of care to covered persons in the event of contract termination between the health carrier and any of its participating providers or in the event of the health carrier's insolvency or other inability to continue operations. Such description shall explain how covered persons will be notified of such contract termination, insolvency or other cessation of operations and transitioned to other participating providers in a timely manner;

(J) The health carrier's process for monitoring access to specialist services in emergency room care, anesthesiology, radiology, hospitalist care and pathology and laboratory services at such health carrier's participating hospitals;

(K) The health carrier's efforts to ensure that its participating providers meet available and appropriate quality of care standards and health outcomes for network plans that such health carrier has designed to include health care providers and facilities that provide high quality of care and health outcomes;

(L) The health carrier's accreditation by the National Committee for Quality Assurance that such health carrier meets said committee's network adequacy requirements or by URAC that such health carrier meets URAC's provider network access and availability standards; and

(M) Any other information required by the commissioner to determine the health carrier's compliance with this section.

(3) A health carrier shall post each access plan on its Internet web site and make such access plan available at the health carrier's business premises in this state and to any person upon request, except that such health carrier may exclude from such posting or publicly available access plan any information such health carrier deems to be proprietary information that, if disclosed, would cause the health carrier's competitors to obtain valuable business information. A health carrier may request the commissioner not to disclose such information under section 1-210.

(i) (1) If the commissioner determines that (A) a health carrier has not contracted with a sufficient number of participating providers to assure that its covered persons have accessible health care services in a geographic area, (B) a health carrier's access plan does not assure reasonable access to covered benefits, (C) a health carrier has entered into a contract that does not conform to the requirements of this section or section 38a-477g, or (D) a health carrier has not complied with a provision of this section or section 38a-477g or 38a-477h, the health carrier shall modify its access plan or implement a corrective action plan, as appropriate, and as directed by the commissioner. The commissioner may take any other action authorized under this title to bring a health carrier into compliance with this section and sections 38a-477g and 38a-477h.

(2) The commissioner may adopt regulations, in accordance with the provisions of chapter 54, to implement the provisions of this section and sections 38a-477g and 38a-477h.

(P.A. 11-58, S. 17; P.A. 16-205, S. 1; P.A. 17-198, S. 31; P.A. 18-115, S. 1; P.A. 22-47, S. 52.)

History: P.A. 11-58 effective January 1, 2012; P.A. 16-205 replaced former provisions with provisions re definitions and health carriers' responsibilities and duties re network adequacy, effective January 1, 2017; P.A. 17-198 amended Subsec. (a)(6) by redefining “health benefit plan”, effective June 30, 2017; P.A. 18-115 amended Subsec. (g) by substituting “ninety days’” for “sixty days’” in Subdiv. (1)(A), adding Subdiv. (1)(C) re contracts between health carriers and participating providers that are hospitals or parent corporations of hospitals, and making a technical change in Subdiv. (2)(B)(ii), effective July 1, 2018; P.A. 22-47 amended Subsec. (c)(1)(B) by requiring that covered persons have access to urgent crisis center services, to the extent such services are available, and defined “emergency services” and “urgent crisis center services”, effective January 1, 2023.

See Sec. 38a-477h re provider directories.

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Sec. 38a-472g. Restrictions applicable to prior authorization or precertification. (a)(1) No insurer, health care center, fraternal benefit society, hospital service corporation or medical service corporation or other entity, delivering, issuing for delivery, renewing, amending or continuing an individual or group health insurance policy in this state providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 or utilization review company performing utilization review for such insurer, center, society, corporation or entity, that issues prior authorization for or precertifies, on or after January 1, 2012, an admission, service, procedure or extension of stay shall reverse or rescind such prior authorization or precertification or refuse to pay for such admission, service, procedure or extension of stay if:

(A) Such insurer, center, society, corporation, entity or company failed to notify the insured's or enrollee's health care provider at least three business days prior to the scheduled date of such admission, service, procedure or extension of stay that such prior authorization or precertification has been reversed or rescinded on the basis of medical necessity, fraud or lack of coverage; and

(B) Such admission, service, procedure or extension of stay has taken place in reliance on such prior authorization or precertification.

(2) The provisions of this subsection shall apply regardless of whether such prior authorization or precertification is required or is requested by an insured's or enrollee's health care provider. Unless reversed or rescinded as set forth in subparagraph (A) of subdivision (1) of this subsection, such prior authorization or precertification shall be effective for not less than sixty days from the date of issuance.

(b) Nothing in subsection (a) of this section shall be construed to authorize benefits or services in excess of those that are provided for in the insured's or enrollee's policy or contract.

(P.A. 11-58, S. 18; P.A. 17-15, S. 37.)

History: P.A. 11-58 effective January 1, 2012; P.A. 17-15 made technical changes in Subsec. (a).

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Sec. 38a-472h. Fees charged by dentists, optometrists and ophthalmologists for noncovered benefits. Notice and posting required. (a) No insurer, health care center, fraternal benefit society, hospital service corporation, medical service corporation or other entity delivering, issuing for delivery, renewing, amending or continuing:

(1) An individual or a group dental plan in this state shall include in any contract with a dentist licensed pursuant to chapter 379 that is entered into, renewed or amended on or after January 1, 2012, any provision that requires such dentist to accept as payment an amount set by such insurer, center, society, corporation or entity for services or procedures provided to an insured or enrollee that are not covered benefits under such insured's or enrollee's plan; or

(2) An individual or a group vision plan in this state shall include in any contract with an optometrist licensed pursuant to chapter 380 or an ophthalmologist licensed pursuant to chapter 370 that is entered into, renewed or amended on or after January 1, 2020, any provision that requires such optometrist or ophthalmologist to accept as payment an amount set by such insurer, center, society, corporation or entity for services, procedures or products provided to an insured or enrollee that are not covered benefits under such insured's or enrollee's plan.

(b) No dentist shall charge more for services or procedures that are not covered benefits than such dentist's usual and customary rate for such services or procedures, and no optometrist or ophthalmologist shall charge more for services, procedures or products that are not covered benefits than such optometrist's or ophthalmologist's usual and customary rate for such services, procedures or products.

“IMPORTANT: If you opt to receive dental services or procedures that are not covered benefits under this plan, a participating dental provider may charge you his or her usual and customary rate for such services or procedures. Prior to providing you with dental services or procedures that are not covered benefits, the dental provider should provide you with a treatment plan that includes each anticipated service or procedure to be provided and the estimated cost of each such service or procedure. To fully understand your coverage, you may wish to review your evidence of coverage document.”

(2) Each evidence of coverage for an individual or a group vision plan shall include the following statement:

“IMPORTANT: If you opt to receive optometric or ophthalmologic services, procedures or products that are not covered benefits under this plan, a participating optometrist or ophthalmologist may charge you his or her usual and customary rate for such services, procedures or products. Prior to providing you with optometric or ophthalmologic services, procedures or products that are not covered benefits, the optometrist or ophthalmologist should provide you with a treatment plan that includes each anticipated service, procedure or product to be provided and the estimated cost of each such service, procedure or product. To fully understand your coverage, you may wish to review your evidence of coverage document.”

(d) Each dentist, optometrist and ophthalmologist shall post, in a conspicuous place, a notice stating that services, procedures or products, as applicable, that are not covered benefits under an insurance policy or plan might not be offered at a discounted rate.

(e) The provisions of this section shall not apply to:

(1) A self-insured plan that covers (A) dental services or procedures, or (B) optometric or ophthalmologic services, procedures or products;

(2) A contract that is incorporated in or derived from a collective bargaining agreement or in which some or all of the material terms are subject to a collective bargaining process;

(3) A contract that is derived from a multiemployer plan, as defined in Section 3 of the Employee Retirement Income Security Act of 1974, as amended from time to time; or

(4) A network of ophthalmologists or optometrists, or both, when servicing a plan or contract described in subdivision (1), (2) or (3) of this subsection.

(P.A. 11-58, S. 19; P.A. 12-145, S. 9; P.A. 15-122, S. 1; P.A. 19-201, S. 1.)

History: P.A. 11-58 effective January 1, 2012; P.A. 12-145 made a technical change in Subsec. (a), effective June 15, 2012; P.A. 15-122 amended Subsec. (a) by designating existing provision re prohibition on dental plans for noncovered benefits as Subdiv. (1) and adding Subdiv. (2) re prohibition on vision plans for noncovered benefits, amended Subsec. (b) by adding references to optometrist and making a technical change, amended Subsec. (c) by designating existing provisions re inclusion of statement in evidence of coverage re noncovered dental services or procedures as Subdiv. (1) and adding Subdiv. (2) re inclusion of statement in evidence of coverage re noncovered optometric services or procedures, amended Subsec. (d) to add reference to optometrist, and amended Subsec. (e) to add reference to optometric services, effective January 1, 2016; P.A. 19-201 added provisions re ophthalmologists and products in Subsecs. (a)(2), (b), (c)(2), (d) and (e)(1), amended Subsec. (a)(2) by substituting “2020” for “2016”, amended Subsec. (e) by adding Subdiv. (3) re multiemployer plans and adding Subdiv. (4) re networks of ophthalmologists or optometrists, and made technical changes, effective January 1, 2020.

See Sec. 20-138b re health care center or preferred provider network offering ophthalmologic care and optometric care.

See Sec. 20-138d re coverage for services of optometrists.

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Sec. 38a-472i. Payment amount of professional services component of covered colonoscopy or endoscopic services. Each insurer, health care center, hospital service corporation, medical service corporation or fraternal benefit society that delivers, issues for delivery, renews, amends or continues an individual or group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 in this state, and contracts directly with a physician or physician group or physician organization to provide medical services under such policy shall, at such contracted physician's or physician's group's or physician's organization's request, establish a payment amount for the physician's professional services component of colonoscopy or endoscopic services covered under such policy, that is the same regardless of where the physician's professional services are performed. Such payment amount for the physician's professional services shall not be less than the amount that would otherwise be paid to such contracted physician or physician group or physician organization if the services are performed at a facility other than an outpatient surgical facility, as defined in section 19a-493b. Nothing in this section shall prohibit a contracted physician or physician group or physician organization from agreeing to a different payment methodology for colonoscopy or endoscopic services.

(P.A. 11-225, S. 3.)

See Secs. 38a-492k and 38a-518k for individual and group health insurance coverage for colorectal cancer screening.

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Sec. 38a-472j. Restrictions applicable to cost-sharing for covered benefits. Regulations. (a) Notwithstanding any provision of the general statutes and to the maximum extent permitted by federal law, no individual or group health insurance policy delivered, issued for delivery, renewed, amended or continued in this state on or after January 1, 2020, providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 shall impose a coinsurance, copayment, deductible or other out-of-pocket expense for a covered benefit in an amount that exceeds the lesser of:

(1) The amount paid to the provider or vendor for the covered benefit, including all discounts, rebates and adjustments, by the insurer, health care center, fraternal benefit society, hospital service corporation, medical service corporation or other entity that delivered, issued for delivery, renewed, amended or continued such policy or an intermediary engaged by such insurer, center, society, corporation or entity;

(2) An amount calculated on the basis of the amount charged for the covered benefit by the provider or vendor, less any discount for such covered benefit and any amount due to, or charged by, an entity if such entity is affiliated with, or owned or controlled by, the insurer, health care center, fraternal benefit society, hospital service corporation, medical service corporation or other entity that delivered, issued for delivery, renewed, amended or continued such policy; or

(3) The amount that the insured would have paid to the provider or vendor for the covered benefit without regard to such policy. If the Insurance Commissioner adopts regulations pursuant to subsection (c) of this section, the commissioner may define such amount in such regulations.

(b) Any violation of subsection (a) of this section shall be deemed an unfair method of competition and unfair and deceptive act or practice in the business of insurance under section 38a-816.

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

(P.A. 19-117, S. 236.)

History: P.A. 19-117 effective January 1, 2020.

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Sec. 38a-472k. Disability income policies. Discretionary clauses prohibited. Regulations. No insurer, health care center, fraternal benefit society, hospital service corporation, medical service corporation or other entity delivering, issuing for delivery, renewing, amending or continuing an individual or group health insurance policy in this state on or after January 1, 2020, providing coverage of the type specified in subdivision (5) of section 38a-469 shall include in such policy a provision reserving discretion to such insurer, center, society, corporation or entity to interpret the terms of such policy, or provide standards for the interpretation or review of such policy, that are inconsistent with the laws of this state.

(P.A. 19-117, S. 244.)

History: P.A. 19-117 effective January 1, 2020.

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Sec. 38a-472l. Participating dental provider contracts. Third-party access. Restrictions. Exceptions. (a) For the purposes of this section:

(1) “Covered person” means a policyholder, subscriber, enrollee or other individual participating in a network dental benefit plan;

(2) “Dentist” means an individual licensed and registered as a dentist under chapter 379;

(3) “Dental office” means a dental office, or an office, laboratory or operation or consultation room in which dental medicine, dental surgery or dental hygiene is carried on as a portion of such office's, laboratory's or room's regular business, that is owned or operated by a dentist who, or a professional corporation organized and existing under chapter 594a for the purpose of rendering professional dental services that, is authorized to own or operate such office, laboratory or room under section 20-122;

(4) “Health carrier” has the same meaning as provided in section 38a-591a;

(5) “Intermediary” means a person authorized to negotiate and execute a health care provider contract with a health carrier on behalf of a dentist, dental office or network;

(6) “Network” means the group or groups of participating dental providers providing dental services under a network dental benefit plan;

(7) “Network dental benefit plan” means an insurance policy or contract, certificate or agreement offered, delivered, issued for delivery, renewed, amended or continued in this state to provide, deliver, arrange for, pay for or reimburse any of the costs of dental services that requires a covered person to use, or creates incentives, including, but not limited to, financial incentives, for a covered person to use, dentists or dental offices that are managed, owned, under contract with or employed by the health carrier or the health carrier's contractor or subcontractor;

(8) “Participating dental provider” means a dentist or dental office that, under a participating dental provider contract with a health carrier or the health carrier's contractor or subcontractor, agrees to provide dental services to the health carrier's covered persons, with an expectation of receiving payment or reimbursement directly or indirectly from the health carrier, other than coinsurance, copayments or deductibles;

(9) “Participating dental provider contract” means a contract between a health carrier, or the health carrier's contractor or subcontractor, and a participating dental provider under which the participating dental provider agrees to provide dental services to the health carrier's covered persons, with an expectation of receiving payment or reimbursement directly or indirectly from the health carrier, other than coinsurance, copayments or deductibles; and

(10) “Third party” means a person that enters into a contract with a health carrier, or the health carrier's contractor or subcontractor, to gain access to the dental services or discounts provided under a participating dental provider contract, but does not mean an employer or other group for whom the health carrier, or the health carrier's contractor or subcontractor, provides administrative services.

(b) (1) Except as provided in subsection (c) of this section, no participating dental provider contract entered into, renewed or amended on or after January 1, 2022, between:

(A) A health carrier and an intermediary or a participating dental provider shall allow a third party to gain access to such participating dental provider contract, except the health carrier may permit a third party to gain access to such participating dental provider contract if, not later than thirty days after the contract permitting such third-party access is executed, renewed or amended or a later date mutually agreed to by the health carrier and such third party, the health carrier allows each participating dental provider that is a party to such participating dental provider contract to:

(i) Decline to participate in such third party's access to such participating dental provider contract, which declination shall not, in and of itself, constitute grounds for the health carrier to terminate or cancel such participating dental provider contract; or

(ii) Contract directly with such third party if such third party is a health carrier; or

(B) A participating dental provider or an intermediary and a health carrier, or the health carrier's contractor or subcontractor, shall permit the health carrier, or the health carrier's contractor or subcontractor, to enter into a contract with a third party that allows the third party to gain access to such participating dental provider contract unless:

(i) Such participating dental provider contract:

(I) Provides that the health carrier, or the health carrier's contractor or subcontractor, may enter into such contract with a third party and grant such access to a third party, and such third party may obtain the rights and responsibilities of such health carrier, or such health carrier's contractor or subcontractor, as if such third party were such health carrier, or such health carrier's contractor or subcontractor;

(II) Clearly identifies the provisions of such participating dental provider contract that allow the health carrier, or the health carrier's contractor or subcontractor, to grant such access to a third party; and

(III) Provides that a participating dental provider under such participating dental provider contract may decline to participate in such third party's access to such participating dental provider contract;

(ii) Such third party agrees to comply with all terms of such participating dental provider contract;

(iii) The health carrier, or the health carrier's contractor or subcontractor, discloses, in writing or by electronic means, to each participating dental provider under such participating dental provider contract the identity of such third party on the date that the health carrier, or the health carrier's contractor or subcontractor, enters into a contract with such third party to allow such third party to gain access to such participating dental provider contract;

(iv) The health carrier, or the health carrier's contractor or subcontractor:

(I) Makes a list containing the name of each third party that enters into a contract with such health carrier, or such health carrier's contractor or subcontractor, that allows such third party to gain access to such participating dental provider contract publicly available on such health carrier's, or such health carrier's contractor's or subcontractor's, Internet web site; and

(II) Updates the list required under subparagraph (B)(iv)(I) of this subdivision at least once every ninety days;

(v) The health carrier, or the health carrier's contractor or subcontractor, requires such third party to identify the source of any discount provided under such participating dental provider contract on each remittance advice or explanation of payment under which such third party takes such discount, except no such identification shall be required for an electronic transaction required under the Health Insurance Portability and Accountability Act of 1996, P.L. 104-191, as amended from time to time;

(vi) If the health carrier, or the health carrier's contractor or subcontractor, intends to terminate such participating dental provider contract, the health carrier, or the health carrier's contractor or subcontractor, sends a written notice to such third party disclosing such intended termination;

(vii) Such third party's right to a discounted rate under such participating dental provider contract ends on the termination date of such participating dental provider contract; and

(viii) The health carrier, or the health carrier's contractor or subcontractor, provides a copy of such participating dental provider contract to any participating dental provider under such participating dental provider contract not later than thirty days after such participating dental provider submits a request to the health carrier, or the health carrier's contractor or subcontractor, for such copy.

(2) No participating dental provider shall be required to provide dental services under a participating dental provider contract if a health carrier, or the health carrier's contractor or subcontractor, enters into a contract with a third party that allows the third party to gain access to the participating dental provider contract in violation of this section.

(3) No health carrier, and no health carrier's contractor or subcontractor, shall refuse to enter into a participating dental provider contract with a dentist or dental office because the dentist or dental office declines to participate in a third party's access to the participating dental provider contract.

(c) The requirements of subsection (b) of this section shall not apply to any contract that grants access to a participating dental provider contract:

(1) To a health carrier or other entity operating in accordance with the same brand licensee program as the health carrier, or the health carrier's contractor or subcontractor, that is a party to the participating dental provider contract;

(2) To an affiliate of the health carrier, or the health carrier's contractor or subcontractor, that is a party to the participating dental provider contract, provided such health carrier, or such health carrier's contractor or subcontractor, makes a list of such affiliates publicly available on such health carrier's, or such health carrier's contractor's or subcontractor's, Internet web site; or

(3) For dental services provided to beneficiaries in this state under the Medicaid program under Title XIX of the Social Security Act, as amended from time to time, or the Children's Health Insurance Program (CHIP) under Title XXI of the Social Security Act, as amended from time to time.

(P.A. 21-187, S. 2.)

History: P.A. 21-187 effective January 1, 2022.

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Sec. 38a-473. Medicare supplement expense factors. Age, gender, previous claim or medical history rating prohibited. (a) No insurance company, fraternal benefit society, hospital service corporation, medical service corporation, health care center or other entity that delivers or issues for delivery Medicare supplement insurance policies or certificates, written, delivered, continued or renewed in this state during the previous calendar year shall incorporate in its rates for Medicare supplement insurance calculated in accordance with sections 38a-495, 38a-495a and 38a-522, and any regulations adopted pursuant to said sections, factors for expenses that exceed one hundred fifty per cent of the average expense ratio for the entire written premium for all lines of health insurance of such company, society, corporation, center or other entity for the previous calendar year.

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

(P.A. 90-243, S. 179, 181; P.A. 91-406, S. 9, 29; P.A. 92-60, S. 20; P.A. 93-239, S. 4; 93-390, S. 3, 8; May 25 Sp. Sess. P.A. 94-1, S. 39, 130; P.A. 05-20, S. 1; P.A. 11-19, S. 27; P.A. 17-15, S. 38.)

History: P.A. 91-406 corrected an internal reference; P.A. 92-60 made provisions applicable to any Medicare supplement policy continued or renewed during the previous calendar year, made provisions applicable to all lines of health insurance and made technical corrections for statutory consistency; P.A. 93-239 made technical corrections for statutory consistency and accuracy; P.A. 93-390 made technical changes for statutory consistency by adding references to “any other entity” and “certificate” and added Subsec. (b) prohibiting the incorporation of factors for age, gender and previous claim or medical condition history, into the insurer's rate schedule, effective January 1, 1994; May 25 Sp. Sess. P.A. 94-1 amended Subsec. (a) by making technical change, effective July 1, 1994; P.A. 05-20 made technical changes and amended Subsec. (b) 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, effective July 1, 2005; P.A. 11-19 amended Subsec. (b) to delete provisions re Medicare supplement plans “H” to “J”; P.A. 17-15 made technical changes.

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Sec. 38a-474. Medicare supplement policy rate increases: Procedure. Age, gender, previous claim or medical history rating prohibited. (a) Any insurance company, fraternal benefit society, hospital service corporation, medical service corporation, health care center or other entity that delivers, issues for delivery, renews, amends or continues in this state any Medicare supplement policy or certificate, as defined in sections 38a-495, 38a-495a and 38a-522, seeking to change its rates shall file a request for such change with the Insurance Department at least sixty days prior to the proposed effective date of such change. The Insurance Department shall review the request and, with respect to requests for an increase in rates, shall hold a public hearing on such increase. The Insurance Commissioner shall approve or deny the request not later than forty-five days after its receipt. The Insurance Commissioner shall adopt regulations, in accordance with chapter 54, to set requirements for the submission of data pertaining to a request to change rates and to define the policies utilized in making a decision on such change in rates.

(P.A. 90-81; P.A. 91-406, S. 10, 29; P.A. 93-390, S. 4, 8; P.A. 94-39, S. 4; P.A. 05-20, S. 2; P.A. 11-19, S. 28; P.A. 12-145, S. 53; P.A. 17-15, S. 39.)

History: P.A. 91-406 corrected an internal reference; P.A. 93-390 added references to “health care centers” and “any other entity” for statutory consistency and added Subsec. (b) prohibiting the incorporation of factors for age, gender and previous claim or medical condition history, into insurer's rate schedule, effective January 1, 1994; P.A. 94-39 substituted “change” for the references to “increase” and added a provision in Subsec. (a) that with respect to requests for an increase in rates a public hearing must be held by the insurance department; P.A. 05-20 made technical changes and amended Subsec. (b) 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, effective July 1, 2005; P.A. 11-19 amended Subsec. (b) to delete provisions re Medicare supplement plans “H” to “J”; P.A. 12-145 amended Subsec. (a) to add “amends” re policy or certificate, delete 1990 and 1994 date references, and make technical changes, effective January 1, 2013; P.A. 17-15 made technical changes.

See Sec. 38a-481 re Medicare supplement policy rates.

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Sec. 38a-475. Precertification of long-term care policies under the Connecticut Partnership for Long-Term Care. Regulations. The Insurance Department shall only precertify long-term care insurance policies that (1) alert the purchaser to the availability of consumer information and public education provided by the Department of Aging and Disability Services pursuant to section 17a-861; (2) offer the option of home and community-based services in addition to nursing home care; (3) in all home care plans, include case management services delivered by an access agency approved by the Office of Policy and Management and the Department of Social Services as meeting the requirements for such agency as defined in regulations adopted pursuant to subsection (e) of section 17b-342, which services shall include, but need not be limited to, the development of a comprehensive individualized assessment and care plan and, as needed, the coordination of appropriate services and the monitoring of the delivery of such services; (4) provide inflation protection; (5) provide for the keeping of records and an explanation of benefit reports on insurance payments which count toward Medicaid resource exclusion; and (6) provide the management information and reports necessary to document the extent of Medicaid resource protection offered and to evaluate the Connecticut Partnership for Long-Term Care. No policy shall be precertified if it requires prior hospitalization or a prior stay in a nursing home as a condition of providing benefits. The commissioner may adopt regulations, in accordance with chapter 54, to carry out the precertification provisions of this section.

(P.A. 89-352, S. 3, 6; P.A. 91-187, S. 3, 4; P.A. 93-262, S. 1, 87; P.A. 95-160, S. 14, 69; P.A. 96-139, S. 12, 13; P.A. 04-10, S. 14; 04-257, S. 62; P.A. 13-125, S. 26; P.A. 17-15, S. 40; June Sp. Sess. P.A. 17-2, S. 314; P.A. 18-169, S. 38; P.A. 19-157, S. 91.)

History: P.A. 91-187 amended Subdivs. (2), (3) and (4) to require all precertified policies to provide that the option of home and community-based services be offered in addition to nursing home care, that all home care plans include case management services and that all such policies provide inflation protection, deleting provision re option to furnish periodic per diem upgrades until insured begins receiving long-term care benefits; P.A. 93-262 authorized substitution of commissioner and department of social services for commissioner and department on aging, effective July 1, 1993; P.A. 95-160 replaced a reference to coordination, assessment and monitoring agencies with access agencies, effective July 1, 1995 (Revisor's note: A reference to “Department of Insurance” was replaced editorially by the Revisors with “Insurance Department” for consistency with customary statutory usage); P.A. 96-139 changed effective date of P.A. 95-160 but without affecting this section; P.A. 04-10, effective October 1, 2004, and P.A. 04-257, effective June 14, 2004, both substituted “17b-251” for “17a-307”; P.A. 13-125 replaced reference to Department of Social Services with reference to Department on Aging in Subdiv. (1), effective July 1, 2013; P.A. 17-15 made a technical change; June Sp. Sess. P.A. 17-2 replaced “Department on Aging” with “Department of Social Services” in Subdiv. (1), effective October 31, 2017; P.A. 18-169 replaced “Department of Social Services” with “Department of Rehabilitation Services” in Subdiv. (1), effective June 14, 2018; P.A. 19-157 replaced “Department of Rehabilitation Services” with “Department of Aging and Disability Services”.

See Sec. 17a-861 re outreach program.

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

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

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

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Sec. 38a-475a. Minimum set of affordable benefit options for long-term care policies. Regulations. (a) For the purposes of this section, “long-term care policy” has the same meaning as provided in section 38a-501 or section 38a-528, as applicable.

(b) The commissioner shall, after consulting with other state governments and conducting a nation-wide review, develop and prescribe a minimum set of affordable benefit options to be offered by an insurance company, fraternal benefit society, hospital service corporation, medical service corporation or health care center that files a rate filing under section 38a-501 or section 38a-528 for an increase in premium rates for a long-term care policy that is for twenty per cent or more. The commissioner shall send to each insurance company, fraternal benefit society, hospital service corporation, medical service corporation or health care center that files such a rate filing a notice disclosing such minimum set of affordable benefit options.

(c) The commissioner may adopt regulations, in accordance with the provisions of chapter 54, to carry out the purposes of this section.

(P.A. 21-150, S. 2.)

History: P.A. 21-150 effective January 1, 2022.

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Sec. 38a-476. Preexisting condition coverage. (a) For the purposes of this section:

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

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

(3) “Preexisting conditions provision” means a policy provision that limits or excludes benefits relating to a condition based on the fact that the condition was present before the effective date of coverage, whether or not any medical advice, diagnosis, care or treatment was recommended or received before such effective date. Genetic information shall not be treated as a condition in the absence of a diagnosis of the condition related to such information. Pregnancy shall not be considered a preexisting condition.

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

(b) (1) No group health insurance plan or insurance arrangement shall impose a preexisting conditions provision on any individual.

(2) No individual health insurance plan or insurance arrangement shall impose a preexisting conditions provision on any individual.

(3) No insurance company, fraternal benefit society, hospital service corporation, medical service corporation or health care center shall refuse to issue an individual health insurance plan or insurance arrangement to any individual solely on the basis that such individual has a preexisting condition.

(P.A. 93-345, S. 3; P.A. 96-87, S. 1–3; 96-177, S. 5; June 18 Sp. Sess. P.A. 97-8, S. 65, 88; P.A. 98-27, S. 14; P.A. 00-121; P.A. 02-24, S. 5; P.A. 07-113, S. 3; P.A. 08-110, S. 2; P.A. 11-58, S. 41; P.A. 14-122, S. 49; P.A. 15-247, S. 8; P.A. 17-15, S. 41; P.A. 19-134, S. 1.)

History: P.A. 96-87 amended Subsec. (a) and added Subsec. (f) to exempt “short-term” policies which provide the prescribed disclosures, effective May 8, 1996; P.A. 96-177 redefined “preexisting conditions provision” to specify that breast cancer check-ups are not medical advice, diagnosis, care or treatment unless evidence of breast cancer is found; June 18 Sp. Sess. P.A. 97-8 redefined “preexisting conditions provision” in Subsec. (a), amended Subsec. (b) to delete references to pregnancy, to substitute “whether physical or mental” for “manifesting themselves or” in Subdiv. (1) and to substitute “whether physical or mental, which manifest themselves” for “manifesting themselves” in Subdiv. (2), amended Subsecs. (c) and (d) to substitute “less than sixty-three days” for “not more than thirty days” and to substitute “sixty-three days” for “thirty days”, added new Subsec. (e) re compliance with the Public Health Service Act, designated former Subsecs. (e) and (f) as Subsecs. (f) and (g) respectively, amending new Subsec. (f) re application dates of Subsec. (e), and added new Subsec. (h) re regulations to enforce HIPAA, effective July 1, 1997; P.A. 98-27 amended Subsec. (d) to substitute “time such individual” for “time such person” and substituted “such individual's initial eligibility” for “their initial eligibility”; P.A. 00-121 amended Subsecs. (c) and (d) by amending time periods from 63 to 120 days and 90 to 150 days, amending application deadline from 63 to 30 days, and making technical changes for purposes of gender neutrality; P.A. 02-24 substituted “their” for “its” in Subsec. (c); P.A. 07-113 amended Subsec. (b)(2) to delete reference to conditions “which manifest themselves”, amended Subsec. (g) to require a short-term health insurance policy which imposes preexisting conditions provision to be subject to conditions, including a requirement for disclosure of a statement re exclusion of coverage under the policy in a conspicuous manner, to provide for a reduction in preexisting conditions exclusion period in the second, third or subsequent policy if an insurer or health care center issues two, three or more consecutive short-term health insurance policies with preexisting conditions provision to the same individual, and to require that nothing in section be construed to require short-term health insurance policy to be issued on a guaranteed issue or guaranteed renewable basis, and amended Subsec. (h) to authorize commissioner to adopt regulations to enforce provisions of section; P.A. 08-110 changed “may” to “shall” and made technical changes in Subsec. (b), effective May 27, 2008; P.A. 11-58 amended Subsec. (b) to prohibit preexisting conditions provision that excludes coverage for individuals 18 years of age and younger in Subdivs. (1) and (2), and added Subdiv. (3) prohibiting issuance refusal of an individual health insurance plan or arrangement to such individuals solely on the basis of a preexisting condition, effective July 2, 2011; P.A. 14-122 made technical changes in Subsec. (a)(2); P.A. 15-247 amended Subsec. (a) by deleting former Subdiv. (4) re definition of “qualifying coverage” and redesignating existing Subdiv. (5) as Subdiv. (4), amended Subsec. (b) by replacing conditions for imposition of preexisting conditions provision with prohibition on such imposition in Subdivs. (1) and (2), deleted former Subsecs. (c) to (f) re coverage for preexisting conditions, redesignated existing Subsec. (g) as Subsec. (c) and amended same to designate existing provisions re short-term health insurance policy as Subdiv. (1) and existing provisions re additional short-term health insurance policies as Subdiv. (2), deleted former Subsec. (h) re adoption of regulations concerning preexisting conditions and portability, and made technical and conforming changes, effective July 10, 2015; P.A. 17-15 made a technical change in Subsec. (a)(1)(B); P.A. 19-134 amended Subsec. (a) by redefining “health insurance plan” in Subdiv.(1) and redefining “preexisting conditions provision” in Subdiv. (3), and deleted Subsec. (c) re short-term health insurance policies issued on a nonrenewable basis for 6 months or less, effective January 1, 2020.

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

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

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

(d) No provision of the general statutes concerning a requirement in the Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191), as amended from time to time, shall be construed to supersede any other provision of the general statutes except to the extent that such other provision prevents the application of a requirement of said act.

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

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

(June 18 Sp. Sess. P.A. 97-8, S. 66, 88; P.A. 17-15, S. 42.)

History: June 18 Sp. Sess. P.A. 97-8 effective July 1, 1997; P.A. 17-15 made technical changes.

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Sec. 38a-476b. Standards re psychotropic drug availability in health plans. Notwithstanding any provision of the general statutes or the regulations of Connecticut state agencies, no mental health care benefit provided under state law, or with state funds or to state employees may, through the use of a drug formulary, list of covered drugs or any other means: (1) Limit the availability of psychotropic drugs that are the most effective therapeutically indicated pharmaceutical treatment with the least probability of adverse side effects; (2) require utilization of psychotropic drugs that are not the most effective therapeutically indicated pharmaceutical treatment with the least probability of adverse side effects; or (3) require a prescribing health care provider to prescribe a supply of an outpatient psychotropic drug that is larger than the supply of such drug that such provider deems clinically appropriate. Nothing in this section shall be construed to limit the authority of a physician to prescribe a drug that is not the most recent pharmaceutical treatment. Nothing in this section shall be construed to prohibit differential copays among pharmaceutical treatments or to prohibit utilization review.

(P.A. 01-171, S. 17; P.A. 21-125, S. 3.)

History: P.A. 21-125 added Subdiv. (3) re outpatient psychotropic drugs and made a conforming change, effective January 1, 2022.

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Sec. 38a-476c. Policies and contracts with variable network and enrollee cost-sharing. Approval. Limitations. (a) The Insurance Commissioner shall approve any health insurance policy or contract, including, but not limited to, a policy or contract filed by a health care center, that uses variable networks and enrollee cost-sharing as set forth in subsection (b) of this section if (1) the policy or contract meets the requirements of this title, (2) the policy or contract form or amendment thereto filed with the commissioner is accompanied by a rate filing for the policy or contract and (3) the commissioner finds that the rate filing reflects a reasonable reduction in premiums or fees as compared to policies or contracts that do not use such variable networks and enrollee cost-sharing.

(b) Such policies and contracts shall be limited to policies and contracts that: (1) Offer choices among provider networks of different size; (2) offer different deductibles depending on the type of health care facility used; or (3) offer prescription drug benefits that use any combination of deductibles, coinsurance not to exceed thirty per cent or copayments, including combinations of such deductibles, coinsurance or copayments at different benefit levels.

(P.A. 05-238, S. 7.)

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

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

Item Number	Item Description
1a	Insured's identification number
2	Patient's name
3	Patient's birth date and sex
4	Insured's name
10a	Patient's condition - employment
10b	Patient's condition - auto accident
10c	Patient's condition - other accident
11	Insured's policy group number
	(if provided on identification card)
11d	Is there another health benefit plan?
17a	Identification number of referring physician or
	advanced practice registered nurse
	(if required by insurer)
21	Diagnosis
24A	Dates of service
24B	Place of service
24D	Procedures, services or supplies
24E	Diagnosis code
24F	Charges
25	Federal tax identification number
28	Total charge
31	Signature of physician, advanced practice
	registered nurse or supplier with date
33	Physician's, advanced practice registered nurse's
	or supplier's billing name,
	address, zip code & telephone number

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

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

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

(P.A. 93-109; P.A. 03-57, S. 2; P.A. 12-197, S. 41.)

History: P.A. 03-57 substituted “Health Care Financing Administration UB-92 health insurance claim form” for “UB-82” in Subsec. (a), added new Subsecs. (b) and (c) re information on HCFA1500 claim form and UB-92 claim form, respectively, redesignated existing Subsec. (b) as Subsec. (d) and made technical changes therein; P.A. 12-197 amended Subsec. (b) by adding references to advanced practice registered nurse in items 17a, 31 and 33 and amended Subsec. (c) by adding reference to advanced practice registered nurse and making a technical change in item 82.

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Sec. 38a-477a. Notification by Insurance Commissioner of required benefits and policy forms. The Insurance Commissioner shall provide written or electronic notification to each insurance company, fraternal benefit society, hospital service corporation, medical service corporation, health care center or any other entity that delivers or issues for delivery, in this state, any individual or group health insurance plan (1) of any benefits required to be provided in such plan pursuant to this chapter, or of any modification to such benefits on or after October 1, 2006, at least thirty days prior to the date such benefits or modification becomes effective, and (2) instructing such company, society, corporation, center or other entity to submit to the Insurance Commissioner, prior to the date such benefits or modification becomes effective or upon the renewal date of the plan, any necessary policy forms, in accordance with the provisions of section 38a-481 or 38a-513, as applicable, that reflect such benefits or modification.

(P.A. 06-188, S. 35; P.A. 08-147, S. 6.)

History: P.A. 08-147 authorized electronic notification provided by commissioner.

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Sec. 38a-477b. Postclaims underwriting prohibited unless approval granted. Application for approval of rescission, cancellation or limitation. Decision. Appeals. Regulations. (a) Unless approval is granted pursuant to subsection (b) of this section, no insurer or health care center may rescind, cancel or limit any policy of insurance, contract, evidence of coverage or certificate that provides coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469 on the basis of written information submitted on, with or omitted from an insurance application by the insured if the insurer or health care center failed to complete medical underwriting and resolve all reasonable medical questions related to the written information submitted on, with or omitted from the insurance application before issuing the policy, contract, evidence of coverage or certificate. No insurer or health care center may rescind, cancel or limit any such policy, contract, evidence of coverage or certificate more than two years after the effective date of the policy, contract, evidence of coverage or certificate.

(b) An insurer or health care center shall apply for approval of such rescission, cancellation or limitation by submitting such written information to the Insurance Commissioner on an application in such form as the commissioner prescribes. Such insurer or health care center shall provide a copy of the application for such approval to the insured or the insured's representative. Not later than seven business days after receipt of the application for such approval, the insured or the insured's representative shall have an opportunity to review such application and respond and submit relevant information to the commissioner with respect to such application. Not later than fifteen business days after the submission of information by the insured or the insured's representative, the commissioner shall issue a written decision on such application. The commissioner shall only approve:

(1) Such rescission or limitation if the commissioner finds that (A) the insured or such insured's representative submitted the written information on or with the insurance application that was fraudulent at the time such application was made, (B) the insured or such insured's representative intentionally misrepresented information therein and such misrepresentation materially affects the risk or the hazard assumed by the insurer or health care center, or (C) the information omitted from the insurance application was intentionally omitted by the insured or such insured's representative and such omission materially affects the risk or the hazard assumed by the insurer or health care center. Such decision shall be mailed to the insured, the insured's representative, if any, and the insurer or health care center; and

(2) Such cancellation in accordance with the provisions set forth in the Public Health Service Act, 42 USC 300gg et seq., as amended from time to time.

(c) Notwithstanding the provisions of chapter 54, any insurer or insured aggrieved by any decision by the commissioner under subsection (b) of this section may, within thirty days after notice of the commissioner's decision is mailed to such insurer and insured, take an appeal therefrom to the superior court for the judicial district of Hartford, which shall be accompanied by a citation to the commissioner to appear before said court. Such citation shall be signed by the same authority, and such appeal shall be returnable at the same time and served and returned in the same manner, as is required in case of a summons in a civil action. Said court may grant such relief as may be equitable.

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

(P.A. 07-113, S. 1; P.A. 11-58, S. 47, 69.)

History: P.A. 11-58 amended Subsec. (b) by replacing “may” with “shall only” re commissioner's approval, designating existing provisions re submission of false information as Subdiv. (1) and amending same by changing provisions re the knowing submission of false information by an insured to the intentional misrepresentation of fraudulent information by an insured, adding Subdiv. (2) re provision governing cancellation of policy in accordance with Public Health Service Act, and making conforming and technical changes, effective July 1, 2011.

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Sec. 38a-477c. Disclosure of state and federal 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 state medical loss ratio and federal medical loss ratio, as both terms are defined in 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; P.A. 11-58, S. 50.)

History: P.A. 11-58 added federal medical loss ratio to information disclosed with application for health insurance coverage and made conforming changes, effective January 1, 2012.

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Sec. 38a-477d. Information to be made available to consumers. Explanations of benefits. Disclosures by health carriers. Specifications by consumers. Restrictions. (a) Each insurer, health care center, hospital service corporation, medical service corporation, fraternal benefit society or other entity that delivers, issues for delivery, renews, amends or continues a health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 in this state, shall:

(1) Make available to consumers, in an easily readable, accessible and understandable format:

(A) The following information for each such policy:

(i) Any coverage exclusions;

(ii) Any restrictions on the use or quantity of a covered benefit, including on prescription drugs or drugs administered in a physician's office or a clinic;

(iii) A specific description of how prescription drugs are included or excluded from any applicable deductible, including a description of other out-of-pocket expenses that apply to such drugs;

(iv) The specific dollar amount of any copayment and the percentage of any coinsurance imposed on each covered benefit, including each covered prescription drug; and

(v) Information regarding any process available to consumers, and all documents necessary, to seek coverage of a noncovered outpatient prescription drug; and

(B) With respect to explanations of benefits issued pursuant to subsections (d) to (i), inclusive, of this section, a statement disclosing that each consumer who is a covered individual and legally capable of consenting to the provision of covered benefits under such policy may specify that such insurer, center, corporation, society or entity, and each third-party administrator, as defined in section 38a-720, providing services to such insurer, center, corporation, society or entity, shall:

(i) Not issue explanations of benefits concerning covered benefits provided to such consumer; or

(ii) (I) Issue explanations of benefits concerning covered benefits provided to such consumer solely to such consumer; and

(II) Use a method specified by such consumer to issue such explanations of benefits solely to such consumer, and provide sufficient space in the statement for such consumer to specify a mailing address or an electronic mail address for such insurer, center, corporation, society, entity or third-party administrator to use to contact such consumer concerning covered benefits provided to such consumer.

(2) Make available to consumers a way to determine accurately:

(A) Whether a specific prescription drug is available under such policy's drug formulary;

(B) The coinsurance, copayment, deductible or other out-of-pocket expense applicable to such drug;

(D) Whether such drug requires prior authorization or the use of step therapy;

(E) Whether specific types of health care specialists are in-network; and

(F) Whether a specific health care provider or hospital is in-network.

(b) (1) Each insurer, health care center, hospital service corporation, medical service corporation, fraternal benefit society or other entity shall make the information and statement required under subsection (a) of this section available to consumers at the time of enrollment and shall post such information and statement on its Internet web site.

(2) The Connecticut Health Insurance Exchange, established pursuant to section 38a-1081, shall post links on its Internet web site to such information and statement for each qualified health plan that is offered or sold through the exchange.

(c) The Insurance Commissioner shall post links on the Insurance Department's Internet web site to any on-line tools or calculators to help consumers compare and evaluate health insurance policies and plans.

(d) Except as provided in subsection (g) of this section, each insurer, health care center, hospital service corporation, medical service corporation, fraternal benefit society or other entity that delivers, issues for delivery, renews, amends or continues a health insurance policy described in subsection (a) of this section, and each third-party administrator, as defined in section 38a-720, providing services to such an insurer, center, corporation, society or entity, shall:

(1) Issue explanations of benefits to consumers who are covered individuals under the policy; and

(2) Permit each consumer who is a covered individual under the policy and legally capable of consenting to the provision of covered benefits to specify, in writing, that such insurer, center, corporation, society, entity or third-party administrator issue explanations of benefits concerning covered benefits provided to such consumer solely to such consumer, and specify, in writing, which of the following methods such insurer, center, corporation, society, entity or third-party administrator shall use to issue such explanations of benefits solely to such consumer:

(A) Mailing such explanations of benefits to such consumer's mailing address or another mailing address specified by such consumer; or

(B) Making such explanations of benefits available to such consumer by electronic means and notifying such consumer by electronic means, including, but not limited to, electronic mail, when such insurer, center, corporation, society, entity or third-party administrator makes each such explanation of benefits available to such consumer by electronic means, provided making such explanations of benefits available to such consumer by electronic means and notifying such consumer by electronic means complies with all applicable federal and state laws and regulations concerning data security, including, but not limited to, 45 CFR Part 160, as amended from time to time, and 45 CFR Part 164, Subparts A and C, as amended from time to time.

(e) Each method specified by a consumer, in writing, pursuant to subdivision (2) of subsection (d) of this section shall be valid until the consumer submits a written specification to the insurer, center, corporation, society, entity or third-party administrator for a different method. Such insurer, center, corporation, society, entity or third-party administrator shall comply with a written specification under this subsection or subdivision (2) of subsection (d) of this section, as applicable, not later than three business days after such insurer, center, corporation, society, entity or third-party administrator receives such specification.

(f) Each insurer, center, corporation, society, entity or third-party administrator that receives a written specification from a consumer pursuant to subdivision (2) of subsection (d) of this section or subsection (e) of this section, as applicable, shall provide the consumer who made such specification with written confirmation that such insurer, center, corporation, society, entity or third-party administrator received such specification, and advise such consumer, in writing, regarding the status of such specification if such consumer contacts such insurer, center, corporation, society, entity or third-party administrator, in writing, regarding such specification.

(g) Each consumer who is a covered individual under a policy described in subsection (a) of this section and is legally capable of consenting to the provision of covered benefits may specify, in writing, that the insurer, center, corporation, society or entity that delivered, issued for delivery, renewed, amended or continued the policy, or a third-party administrator providing services to such insurer, center, corporation, society or entity, not issue explanations of benefits pursuant to subsections (d) to (f), inclusive, of this section if such explanations of benefits concern covered benefits that were provided to such consumer. Such insurer, center, corporation, society, entity or third-party administrator shall not require such consumer to provide any explanation regarding the basis for such consumer's specification, unless such explanation is required by applicable law or pursuant to an order issued by a court of competent jurisdiction.

(h) Each insurer, center, corporation, society or entity that delivers, issues for delivery, renews, amends or continues a policy described in subsection (a) of this section, and each third-party administrator providing services to such insurer, center, corporation, society or entity, shall disclose to each consumer who is a covered individual under the policy such consumer's ability to submit specifications pursuant to subsections (d) to (g), inclusive, of this section. Such disclosure shall be in plain language and displayed or printed, as applicable, clearly and conspicuously in all evidence of coverage documents, privacy communications, explanations of benefits and Internet web sites that are maintained by such insurer, center, corporation, society, entity or third-party administrator and accessible to consumers in this state.

(i) No insurer, center, corporation, society or entity that is subject to subsections (d) to (h), inclusive, of this section shall require a consumer or policyholder to waive any right to limit disclosure under subsections (d) to (h), inclusive, of this section as a precondition to delivering, issuing for delivery, renewing, amending or continuing a policy described in subsection (a) of this section to the consumer or policyholder. Nothing in this subsection or subsections (d) to (h), inclusive, of this section shall be construed to limit a consumer's or policyholder's ability to request review of an adverse determination.

(P.A. 15-146, S. 7; P.A. 17-15, S. 43, 44; P.A. 18-41, S. 11; P.A. 21-22, S. 1.)

History: P.A. 15-146 effective January 1, 2016; P.A. 17-15 made technical changes in Subsecs. (a)(2)(D) and (c); P.A. 18-41 amended Subsec. (a)(1) by adding “, accessible” and Subpara. (E) re coverage of noncovered outpatient prescription drugs, effective January 1, 2020; P.A. 21-22 amended Subsec. (a) by dividing existing Subdiv. (1) into Subdivs. (1) and (1)(A), redesignating existing Subdivs. (1)(A) to (1)(E) as Subdivs. (1)(A)(i) to (1)(A)(v), adding new Subdiv. (1)(B) re statement disclosing information re explanations of benefits and making technical and conforming changes, amended Subsec. (b) by adding references to statement and added Subsecs. (d) to (i) re explanations of benefits, disclosures and prohibitions, effective January 1, 2023.

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Sec. 38a-477e. Health carriers to maintain Internet web site and toll-free telephone number. Available information. Exception. (a) On and after January 1, 2017, each health carrier, as defined in section 19a-755b, shall maintain an Internet web site and toll-free telephone number that enables consumers to request and obtain: (1) Information on in-network costs for inpatient admissions, health care procedures and services, including (A) the allowed amount for, at a minimum, admissions and procedures reported to the executive director of the Office of Health Strategy pursuant to section 19a-755b for each health care provider in the state; (B) the estimated out-of-pocket costs that a consumer would be responsible for paying for any such admission or procedure that is medically necessary, including any facility fee, coinsurance, copayment, deductible or other out-of-pocket expense; and (C) data or other information concerning (i) quality measures for the health care provider, (ii) patient satisfaction, to the extent such information is available, (iii) a directory of participating providers, as defined in section 38a-472f, in accordance with the provisions of section 38a-477h; and (2) information on out-of-network costs for inpatient admissions, health care procedures and services.

(b) A health carrier shall advise the consumer when providing the information on out-of-pocket costs that the amounts are estimates and that the consumer's actual cost may vary due to health care provider contractual changes, the need for unforeseen services that arise out of the proposed admission or procedure or other circumstances.

(c) The provisions of this section shall not apply to a health carrier with less than forty thousand covered lives in the state. If in any year, a health carrier exceeds forty thousand covered lives in the state, the provisions of this section shall begin to apply on January first in the following year.

(P.A. 15-146, S. 5; P.A. 16-77, S. 3; 16-205, S. 5; P.A. 17-15, S. 45; June Sp. Sess. P.A. 17-2, S. 123; P.A. 18-91, S. 6.)

History: P.A. 16-77 amended Subsec. (a) by replacing “July 1, 2016” with “January 1, 2017”, and added Subsec. (c) re health carriers to which provisions of section do not apply, effective June 2, 2016; P.A. 16-205 amended Subsec. (a) by adding reference to Sec. 38a-1084a, deleting former Subdiv. (1)(C)(iii) to (1)(C)(v) and adding new Subdiv. (1)(C)(iii) re directory of participating providers, effective January 1, 2017; P.A. 17-15 amended Subsec. (a)(1)(C)(iii) by replacing reference to Sec. 38a-472f with reference to Sec. 38a-477h; June Sp. Sess. P.A. 17-2 amended Subsec. (a) by replacing “38a-1084a” with “19a-755b”, effective October 31, 2017; P.A. 18-91 amended Subsec. (a) by replacing “exchange” with “executive director of the Office of Health Strategy”, effective May 14, 2018.

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Sec. 38a-477f. Contract provision prohibiting certain disclosures prohibited. (a) On and after January 1, 2016, no contract entered into or renewed between a health care provider and a health carrier shall contain a provision prohibiting disclosure of (1) billed or allowed amounts, reimbursement rates or out-of-pocket costs, or (2) any data to the all-payer claims database program established under section 19a-755a. Information described in subdivisions (1) and (2) of this subsection may be used to assist consumers and institutional purchasers in making informed decisions regarding their health care and informed choices among health care providers and allow comparisons between prices paid by various health carriers to health care providers.

(b) On and after October 1, 2017, no contract entered into between a health care provider, or any agent or vendor retained by the health care provider to provide data or analytical services to evaluate and manage health care services provided to the health carrier's plan participants, and a health carrier shall contain a provision prohibiting disclosure of (1) billed or allowed amounts, reimbursement rates or out-of-pocket costs, or (2) any data to the all-payer claims database program established under section 19a-755a. Information described in subdivisions (1) and (2) of this subsection may be used to assist consumers and institutional purchasers in making informed decisions regarding their health care and informed choices among health care providers and allow comparisons between prices paid by various health carriers to health care providers.

(c) If a contract described in subsection (a) or (b) of this section, whichever is applicable, contains a provision prohibited under the applicable subsection, such provision shall be void and unenforceable. The invalidity or unenforceability of any contract provision under this subsection shall not affect any other provision of the contract.

(P.A. 15-146, S. 4; P.A. 17-241, S. 3; June Sp. Sess. P.A. 17-2, S. 122.)

History: P.A. 17-241 designated existing provisions re contract entered into on and after January 1, 2016 between health care provider and health carrier as Subsec. (a) and amending same to replace “and (2)” with “or (2)”, and replace “for the purpose of assisting” with “information described in subdivisions (1) and (2) of this subsection may be used to assist”, added Subsec. (b) re contract entered into on and after October 1, 2017 between health care provider, or its agent or vendor, and health carrier, and added Subsec. (c) re contract provisions prohibited under subsection to be void and unenforceable; June Sp. Sess. P.A. 17-2 amended Subsecs. (a)(2) and (b)(2) by replacing “38a-1091” with “19a-755a”, effective October 31, 2017.

See Sec. 19a-755b re applicable definitions.

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Sec. 38a-477g. Contracts between health carriers and participating providers. (a) As used in this section: (1) “Covered person”, “facility” and “health carrier” have the same meanings as provided in section 38a-591a, (2) “health care provider” has the same meaning as provided in subsection (a) of section 38a-477aa, and (3) “intermediary”, “network”, “network plan” and “participating provider” have the same meanings as provided in subsection (a) of section 38a-472f.

(b) (1) Each contract entered into, renewed or amended on or after January 1, 2017, between a health carrier and a participating provider shall include:

(A) A hold harmless provision that specifies protections for covered persons. Such provision shall include the following statement or a substantially similar statement: “Provider agrees that in no event, including, but not limited to, nonpayment by the health carrier or intermediary, the insolvency of the health carrier or intermediary, or a breach of this agreement, shall the provider bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against a covered person or a person (other than the health carrier or intermediary) acting on behalf of the covered person for services provided pursuant to this agreement. This agreement does not prohibit the provider from collecting coinsurance, deductibles or copayments, as specifically provided in the evidence of coverage, or fees for uncovered services delivered on a fee-for-service basis to covered persons. Nor does this agreement prohibit a provider (except for a health care provider who is employed full-time on the staff of a health carrier and has agreed to provide services exclusively to that health carrier's covered persons and no others) and a covered person from agreeing to continue services solely at the expense of the covered person, as long as the provider has clearly informed the covered person that the health carrier does not cover or continue to cover a specific service or services. Except as provided herein, this agreement does not prohibit the provider from pursuing any available legal remedy.”;

(B) A provision that in the event of a health carrier or intermediary insolvency or other cessation of operations, the participating provider's obligation to deliver covered health care services to covered persons without requesting payment from a covered person other than a coinsurance, copayment, deductible or other out-of-pocket expense for such services will continue until the earlier of (i) the termination of the covered person's coverage under the network plan, including any extension of coverage provided under the contract terms or applicable state or federal law for covered persons who are in an active course of treatment, as set forth in subdivision (2) of subsection (g) of section 38a-472f, or are totally disabled, or (ii) the date the contract between the health carrier and the participating provider would have terminated if the health carrier or intermediary had remained in operation, including any extension of coverage required under applicable state or federal law for covered persons who are in an active course of treatment or are totally disabled;

(C) (i) A provision that requires the participating provider to make health records available to appropriate state and federal authorities involved in assessing the quality of care provided to, or investigating grievances or complaints of, covered persons, and (ii) a statement that such participating provider shall comply with applicable state and federal laws related to the confidentiality of medical and health records and a covered person's right to view, obtain copies of or amend such covered person's medical and health records; and

(D) (i) If such contract is entered into, renewed or amended before July 1, 2022, definitions of what is considered timely notice and a material change for the purposes of subparagraph (A) of subdivision (2) of subsection (c) of this section, or (ii) if such contract is entered into, renewed or amended on or after July 1, 2022, (I) a statement disclosing the ninety-day advance written notice requirement established under subparagraph (B) of subdivision (2) of subsection (c) of this section and what is considered a material change for the purposes of subdivision (2) of subsection (c) of this section, and (II) provisions affording the participating provider a right to appeal any proposed change to the provisions, other documents, provider manuals or policies disclosed pursuant to subdivision (1) of subsection (c) of this section.

(2) The contract terms set forth in subparagraphs (A) and (B) of subdivision (1) of this subsection shall (A) be construed in favor of the covered person, (B) survive the termination of the contract regardless of the reason for the termination, including the insolvency of the health carrier, and (C) supersede any oral or written agreement between a health care provider and a covered person or a covered person's authorized representative that is contrary to or inconsistent with the requirements set forth in subdivision (1) of this subsection.

(3) No contract subject to this subsection shall include any provision that conflicts with the provisions contained in the network plan or required under this section, section 38a-472f or section 38a-477h.

(4) No health carrier or participating provider that is a party to a contract under this subsection shall assign or delegate any right or responsibility required under such contract without the prior written consent of the other party.

(c) (1) At the time a contract subject to subsection (b) of this section is signed, the health carrier or such health carrier's intermediary shall disclose to a participating provider:

(A) All provisions and other documents incorporated by reference in such contract; and

(B) If such contract is entered into, renewed or amended on or after July 1, 2022, all provider manuals and policies incorporated by reference in such contract, if any.

(2) While such contract is in force, the health carrier shall:

(A) If such contract is entered into, renewed or amended before July 1, 2022, timely notify a participating provider of any change to the provisions or other documents specified under subparagraph (A) of subdivision (1) of this subsection that will result in a material change to such contract; or

(B) If such contract is entered into, renewed or amended on or after July 1, 2022, provide to a participating provider at least ninety days' advance written notice of any change to the provisions or other documents specified under subparagraph (A) of subdivision (1) of this subsection, and any change to the provider manuals and policies specified under subparagraph (B) of subdivision (1) of this subsection, that will result in a material change to such contract or the procedures that a participating provider must follow pursuant to such contract.

(d) (1) (A) Each contract between a health carrier and an intermediary entered into, renewed or amended on or after January 1, 2017, shall satisfy the requirements of this subsection.

(B) Each intermediary and participating providers with whom such intermediary contracts shall comply with the applicable requirements of this subsection.

(2) No health carrier shall assign or delegate to an intermediary such health carrier's responsibilities to monitor the offering of covered benefits to covered persons. To the extent a health carrier assigns or delegates to an intermediary other responsibilities, such health carrier shall retain full responsibility for such intermediary's compliance with the requirements of this section.

(3) A health carrier shall have the right to approve or disapprove the participation status of a health care provider or facility in such health carrier's own or a contracted network that is subcontracted for the purpose of providing covered benefits to the health carrier's covered persons.

(4) A health carrier shall maintain at its principal place of business in this state copies of all intermediary subcontracts or ensure that such health carrier has access to all such subcontracts. Such health carrier shall have the right, upon twenty days' prior written notice, to make copies of any intermediary subcontracts to facilitate regulatory review.

(5) (A) Each intermediary shall, if applicable, (i) transmit to the health carrier documentation of health care services utilization and claims paid, and (ii) maintain at its principal place of business in this state, for a period of time prescribed by the commissioner, the books, records, financial information and documentation of health care services received by covered persons, in a manner that facilitates regulatory review, and shall allow the commissioner access to such books, records, financial information and documentation as necessary for the commissioner to determine compliance with this section and section 38a-472f.

(B) Each health carrier shall monitor the timeliness and appropriateness of payments made by its intermediary to participating providers and of health care services received by covered persons.

(6) In the event of the intermediary's insolvency, a health carrier shall have the right to require the assignment to the health carrier of the provisions of a participating provider's contract that address such participating provider's obligation to provide covered benefits. If a health carrier requires such assignment, such health carrier shall remain obligated to pay the participating provider for providing covered benefits under the same terms and conditions as the intermediary prior to the insolvency.

(e) The commissioner shall not act to arbitrate, mediate or settle (1) disputes regarding a health carrier's decision not to include a health care provider or facility in such health carrier's network or network plan, or (2) any other dispute between a health carrier, such health carrier's intermediary or one or more participating providers, that arises under or by reason of a participating provider contract or the termination of such contract.

(P.A. 16-205, S. 2; June Sp. Sess. P.A. 21-2, S. 83.)

History: P.A. 16-205 effective January 1, 2017; June Sp. Sess. P.A. 21-2 amended Subsec. (b)(1)(D) by redesignating existing provisions as Subpara. (D)(i) and amended same by adding provision re contracts entered into, renewed or amended before July 1, 2022, and added Subpara. (D)(ii) re contracts entered into, renewed or amended on or after July 1, 2022, amended Subsec. (c) by redesignating existing provision in former Subdiv. (1) re provisions and documents incorporated by reference into contract as Subpara. (A), adding Subpara. (B) re contracts entered into, renewed or amended on or after July 1, 2022, and provider manuals and policies incorporated by reference therein, redesignating existing provisions in Subdiv. (2) re timely notice re changes for contracts entered into, renewed or amended before July 1, 2022 as Subpara. (A) and added Subpara. (B) re notice re changes for contracts entered into, renewed, or amended on or after July 1, 2022, and made technical and conforming changes.

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Sec. 38a-477h. Participating provider directories. (a) As used in this section: (1) “Covered person”, “facility” and “health carrier” have the same meanings as provided in section 38a-591a, (2) “health care provider” has the same meaning as provided in subsection (a) of section 38a-477aa, and (3) “intermediary”, “network”, “network plan” and “participating provider” have the same meanings as provided in subsection (a) of section 38a-472f.

(b) (1) Each health carrier shall post on its Internet web site a current and accurate participating provider directory, updated at least monthly, for each of its network plans. The health carrier shall ensure that consumers are able to view all of the current participating providers for a network plan through a clearly identifiable link or tab on such health carrier's Internet web site, without being required to create or access an account or enter a policy or contract number.

(2) Each health carrier shall provide, upon request from a covered person or a covered person's representative, a print copy of such directory or of requested information from such directory.

(c) (1) A health carrier shall include in each such electronic or print directory the following information in plain language: (A) A description of the criteria the health carrier used to build its network; (B) if applicable, a description of the criteria the health carrier used to tier its participating providers; (C) if applicable, a description of how the health carrier designates the different participating provider tiers or levels in the network and identifies, for each specific participating provider, in which tier each is placed, such as by name, symbols or grouping, to allow a consumer to be able to identify the participating provider tiers; and (D) if applicable, a statement that authorization or referral may be required to access some participating providers.

(2) Each such directory shall also include a customer service electronic mail address and telephone number or an Internet web site address that covered persons or consumers may use to notify the health carrier of any inaccurate participating provider information in such directory.

(3) Each health carrier shall make it clear for each such electronic or print directory which directory applies to which network plan, such as by including the specific name of the network plan as marketed and issued in this state.

(4) Each such electronic or print directory shall accommodate the communication needs of individuals with disabilities and include an Internet web site address or information regarding available assistance for individuals with limited English proficiency.

(d) (1) The health carrier shall make available through an electronic participating provider directory, for each of its network plans, the following information in a searchable format:

(A) For health care providers, (i) the health care provider's name, gender, participating office location or locations, specialty, if applicable, medical group affiliations, if any, facility affiliations, if applicable, participating facility affiliations, if applicable, (ii) any languages other than English spoken by such health care provider, (iii) whether such health care provider is accepting new patients, and (iv) if such health care provider is accepting new patients, whether such health care provider is accepting new patients on an outpatient services basis;

(B) For hospitals, the hospital name, the hospital type, such as acute, rehabilitation, children's or cancer, the participating hospital location and the hospital's accreditation status; and

(C) For facilities other than hospitals, by type, the facility name, the facility type, the types of health care services performed at the facility and the participating facility location or locations and telephone number or numbers.

(2) In addition to the information required under subdivision (1) of this subsection, the health carrier shall make available through the electronic directory specified under subdivision (1) of this subsection, for each of its network plans, the following information:

(A) For health care providers, the health care provider's contact information, board certification and any languages other than English spoken by clinical staff, if applicable;

(B) For hospitals, the hospital's telephone number; and

(3) (A) Each health carrier shall make available in print, upon request, the following participating provider directory information for the applicable network plan:

(i) For health care providers, (I) the health care provider's name, contact information, specialty, if applicable and participating office location or locations, (II) any languages other than English spoken by such health care provider, (III) whether such health care provider is accepting new patients, and (IV) if such health care provider is accepting new patients, whether such health care provider is accepting new patients on an outpatient services basis;

(ii) For hospitals, the hospital name, the hospital type, such as acute, rehabilitation, children's or cancer and the participating hospital location and telephone number; and

(iii) For facilities other than hospitals, by type, the facility name, the facility type, the types of health care services performed at the facility and the participating facility location or locations and telephone number or numbers.

(B) Each health carrier shall include with the print directory information under subparagraph (A) of this subdivision and in the print participating provider directory under subdivision (2) of subsection (a) of this section a statement that the information provided or included is accurate as of the date of printing, that covered persons or prospective covered persons should consult the health carrier's electronic participating provider directory on such health carrier's Internet web site and that covered persons may call the telephone number on such covered person's insurance card for more information.

(4) For the information required to be included in a participating provider directory pursuant to subdivisions (1) and (2) of this subsection, each health carrier shall make available through such directory the sources of such information and any limitations on such information, if applicable.

(e) Each health carrier shall periodically audit at least a reasonable sample size of its participating provider directories for accuracy and retain documentation of such audit to be made available to the commissioner upon request.

(P.A. 16-205, S. 3; P.A. 17-154, S. 1.)

History: P.A. 16-205 effective January 1, 2017; P.A. 17-154 amended Subsec. (d) by adding Subdivs. (1)(A)(iv) and (3)(A)(i)(IV) re disclosure of information concerning health care providers accepting new patients on an outpatient services basis and made technical changes, effective January 1, 2018.

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Secs. 38a-477i to 38a-477z. Reserved for future use.

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Sec. 38a-477aa. Cost-sharing and health care provider reimbursements for emergency services, urgent crisis center services and surprise bills. (a) As used in this section:

(1) “Emergency condition” has the same meaning as “emergency medical condition”, as provided in section 38a-591a.

(2) “Emergency services” means, with respect to an emergency condition, (A) a medical screening examination as required under Section 1867 of the Social Security Act, as amended from time to time, that is within the capability of a hospital emergency department, including ancillary services routinely available to such department to evaluate such condition, and (B) such further medical examinations and treatment required under said Section 1867 to stabilize such individual that are within the capability of the hospital staff and facilities.

(3) “Health care plan” means an individual or a group health insurance policy or health benefit plan that provides coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469.

(4) “Health care provider” means an individual licensed to provide health care services under chapters 370 to 373, inclusive, chapters 375 to 383b, inclusive, and chapters 384a to 384c, inclusive.

(5) “Health carrier” means an insurance company, health care center, hospital service corporation, medical service corporation, fraternal benefit society or other entity that delivers, issues for delivery, renews, amends or continues a health care plan in this state.

(6) (A) “Surprise bill” means a bill for health care services, other than emergency services or urgent crisis center services, received by an insured for services rendered by an out-of-network health care provider, where such services were rendered by (i) such out-of-network provider at an in-network facility, during a service or procedure performed by an in-network provider or during a service or procedure previously approved or authorized by the health carrier and the insured did not knowingly elect to obtain such services from such out-of-network provider, or (ii) a clinical laboratory, as defined in section 19a-490, that is an out-of-network provider, upon the referral of an in-network provider.

(B) “Surprise bill” does not include a bill for health care services received by an insured when an in-network health care provider was available to render such services and the insured knowingly elected to obtain such services from another health care provider who was out-of-network.

(7) “Urgent crisis center” means a center licensed by the Department of Children and Families that is dedicated to treating children's urgent mental or behavioral health needs.

(8) “Urgent crisis center services” means pediatric mental and behavioral health services provided at an urgent crisis center.

(b) (1) No health carrier shall require prior authorization for rendering emergency services or urgent crisis center services to an insured.

(2) No health carrier shall impose, for emergency services rendered to an insured by an out-of-network health care provider or urgent crisis center services rendered to an insured at an out-of-network urgent crisis center, a coinsurance, copayment, deductible or other out-of-pocket expense that is greater than the coinsurance, copayment, deductible or other out-of-pocket expense that would be imposed if such emergency services were rendered by an in-network health care provider or such urgent crisis center services were rendered at an in-network urgent crisis center.

(3) (A) If emergency services were rendered to an insured by an out-of-network health care provider, such health care provider may bill the health carrier directly and the health carrier shall reimburse such health care provider the greatest of the following amounts: (i) The amount the insured's health care plan would pay for such services if rendered by an in-network health care provider; (ii) the usual, customary and reasonable rate for such services; or (iii) the amount Medicare would reimburse for such services. As used in this subparagraph, “usual, customary and reasonable rate” means the eightieth percentile of all charges for the particular health care service performed by a health care provider in the same or similar specialty and provided in the same geographical area, as reported in a benchmarking database maintained by a nonprofit organization specified by the Insurance Commissioner. Such organization shall not be affiliated with any health carrier.

(B) If urgent crisis center services were rendered to an insured at an out-of-network urgent crisis center, such urgent crisis center may bill the health carrier directly for such urgent crisis center services. The health carrier shall reimburse such out-of-network urgent crisis center or insured, as applicable, for such urgent crisis center services at the in-network rate under the insured's health care plan as payment in full, unless such health carrier and urgent crisis center agree otherwise.

(C) Nothing in subparagraph (A) or (B) of this subdivision shall be construed to prohibit a health carrier and out-of-network health care provider or urgent crisis center from agreeing to a reimbursement amount that is greater than the minimum reimbursement amount established in subparagraph (A) or (B) of this subdivision, as applicable.

(1) An insured shall only be required to pay the applicable coinsurance, copayment, deductible or other out-of-pocket expense that would be imposed for such health care services if such services were rendered by an in-network health care provider; and

(2) A health carrier shall reimburse the out-of-network health care provider or insured, as applicable, for health care services rendered at the in-network rate under the insured's health care plan as payment in full, unless such health carrier and health care provider agree otherwise.

(d) If health care services were rendered to an insured by an out-of-network health care provider and the health carrier failed to inform such insured, if such insured was required to be informed, of the network status of such health care provider pursuant to subdivision (3) of subsection (d) of section 38a-591b, the health carrier shall not impose a coinsurance, copayment, deductible or other out-of-pocket expense that is greater than the coinsurance, copayment, deductible or other out-of-pocket expense that would be imposed if such services were rendered by an in-network health care provider.

(e) The provisions of this section shall apply to a high deductible health plan, as that term is used in subsection (f) of section 38a-493 or subsection (f) of section 38a-520, as applicable, to the maximum extent permitted by federal law, except if such plan is used to establish a medical savings account or an Archer MSA pursuant to Section 220 of the Internal Revenue Code of 1986, or any subsequent corresponding internal revenue code of the United States, as amended from time to time, or a health savings account pursuant to Section 223 of said Internal Revenue Code, as amended from time to time, the provisions of this section shall apply to such plan to the maximum extent that (1) is permitted by federal law, and (2) does not disqualify such account for the deduction allowed under said Section 220 or 223, as applicable.

(P.A. 15-146, S. 9; P.A. 19-117, S. 240; P.A. 22-47, S. 49; 22-58, S. 30.)

History: P.A. 15-146 effective July 1, 2016; P.A. 19-117 amended Subsec. (a)(6)(A) by redefining “surprise bill”, effective January 1, 2020; P.A. 22-47 amended Subsec. (a) to redefine “surprise bill” in Subdiv. (6)(A) and add definitions of “urgent crisis center” and “urgent crisis center services” in Subdivs. (7) and (8), respectively, and made technical changes, amended Subsec. (b) to provide that cost-sharing and health care provider reimbursement requirements apply to urgent crisis center services, added new Subdiv. (3)(B) re carrier required to reimburse out-of-network urgent crisis center or insured at in-network rate for services, redesignated existing Subdiv. (3)(B) as Subdiv. (3)(C) and made technical and conforming changes, and added Subsec. (e) re applicability to high deductible health plans, effective January 1, 2023; P.A. 22-58 amended Subsec. (a)(6)(A) by replacing “19a-30” with “19a-490”.

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Sec. 38a-477bb. Cost-sharing re facility fees. (a) As used in this section, “campus”, “facility fee”, “health system”, “hospital” and “hospital-based facility” have the same meanings as provided in section 19a-508c.

(b) (1) Each health insurer, health care center or other entity that delivers, issues for delivery, renews, amends or continues, on or after January 1, 2016, an individual or a group health insurance policy or health benefit plan providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 in this state, and includes in a contract entered into, renewed or amended on or after October 1, 2015, with a hospital, a health system or a hospital-based facility, reimbursement to such hospital, health system or hospital-based facility for a facility fee for outpatient health care services that are provided at a hospital-based facility located off-site from a hospital campus, shall not impose any separate copayment for such fee.

(2) With respect to an insured covered under such policy or plan, who has not satisfied the deductible applicable to such policy or plan at the time of the provision of the applicable health care service, no such hospital, health system or hospital-based facility may collect from such insured for any applicable facility fee more than the facility fee reimbursement rate agreed to by such insurer, center or other entity pursuant to such contract.

(P.A. 15-146, S. 14.)

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Sec. 38a-477cc. Contracts for pharmacy services with health carriers or pharmacy benefits managers. (a) No contract for pharmacy services entered into in the state between a health carrier, as defined in section 38a-591a, or pharmacy benefits manager, as defined in section 38a-479aaa, and a pharmacy or pharmacist shall:

(1) On and after January 1, 2018, contain a provision prohibiting or penalizing, including through increased utilization review, reduced payments or other financial disincentives, a pharmacist's disclosure to an individual purchasing prescription medication of information regarding:

(A) The cost of the prescription medication to the individual; or

(B) The availability of any therapeutically equivalent alternative medications or alternative methods of purchasing the prescription medication, including, but not limited to, paying a cash price, that are less expensive than the cost of the prescription medication to the individual; and

(2) On and after January 1, 2020, contain a provision permitting the health carrier or pharmacy benefits manager to recoup, directly or indirectly, from a pharmacy or pharmacist any portion of a claim that such health carrier or pharmacy benefits manager has paid to the pharmacy or pharmacist, unless such recoupment is permitted under section 38a-479iii or required by applicable law.

(b) (1) On and after January 1, 2018, no health carrier or pharmacy benefits manager shall require an individual to make a payment at the point of sale for a covered prescription medication in an amount greater than the lesser of:

(A) The applicable copayment for such prescription medication;

(B) The allowable claim amount for the prescription medication; or

(C) The amount an individual would pay for the prescription medication if the individual purchased the prescription medication without using a health benefit plan, as defined in section 38a-591a, or any other source of prescription medication benefits or discounts.

(2) For the purposes of this subsection, “allowable claim amount” means the amount the health carrier or pharmacy benefits manager has agreed to pay the pharmacy for the prescription medication.

(c) Any provision of a contract that violates the provisions of this section shall be void and unenforceable. Any general business practice that violates the provisions of this section shall constitute an unfair trade practice pursuant to chapter 735a. The invalidity or unenforceability of any contract provision under this subsection shall not affect any other provision of the contract.

(d) The Insurance Commissioner may:

(1) Enforce the provisions of this section pursuant to chapter 697; and

(2) Upon request, audit a contract for pharmacy services for compliance with the provisions of this section.

(P.A. 17-241, S. 1; P.A. 19-199, S. 1.)

History: P.A. 19-199 amended Subsec. (a) by deleting reference to January 1, 2018, designating existing provisions re contract for pharmacy services as new Subdiv. (1) and amending same by adding reference to January 1, 2018, redesignating existing Subdiv. (1) as Subpara. (A) and redesignating existing Subdiv. (2) as Subpara. (B), and adding new Subdiv. (2) re contract for pharmacy services on and after January 1, 2020, amended Subsec. (b) by designating existing provisions re payment at point of sale for prescription medication as new Subdiv. (1), redesignating existing Subdiv. (1) as Subpara. (A), redesignating existing Subdivs. (2) and (3) as Subparas. (B) and (C), and designating existing provision defining “allowable claim amount” as Subdiv. (2), and made technical and conforming changes.

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Sec. 38a-477dd. Contracts with health carriers. Certain provisions concerning disclosures to covered persons prohibited. Notwithstanding any provision of the general statutes, and to the maximum extent permitted by applicable law, no contract entered into or amended by a health carrier, as defined in section 38a-591a, on or after January 1, 2020, shall contain any provision prohibiting or penalizing, including, but not limited to, through increased utilization review, reduced payments or other financial disincentives, disclosure of any information to a covered person, as defined in section 38a-591a, concerning:

(1) The cost of a covered benefit, including, but not limited to, the cash price of a covered benefit; or

(2) The availability and cost of any health care service or product that is therapeutically equivalent to a covered benefit, including, but not limited to, the cash price of any such health care service or product.

(P.A. 19-117, S. 238.)

History: P.A. 19-117 effective January 1, 2020.

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Sec. 38a-477ee. Mental health and substance use disorder benefits. Nonquantitative treatment limitations. Reports. Public hearings. Regulations. (a) For the purposes of this section:

(1) “Health carrier” has the same meaning as provided in section 38a-1080;

(2) “Mental health and substance use disorder benefits” means all benefits for the treatment of a mental health condition or a substance use disorder that (A) falls under one or more of the diagnostic categories listed in the chapter concerning mental disorders in the most recent edition of the International Classification of Diseases, or (B) is a mental disorder, as that term is defined in the most recent edition of the American Psychiatric Association's “Diagnostic and Statistical Manual of Mental Disorders”; and

(3) “Nonquantitative treatment limitation” means a limitation that cannot be expressed numerically but otherwise limits the scope or duration of a covered benefit.

(b) Not later than March 1, 2021, and annually thereafter, each health carrier shall submit a report to the Insurance Commissioner, in a form and manner prescribed by the commissioner, containing the following information for the calendar year immediately preceding:

(1) A description of the processes that such health carrier used to develop and select criteria to assess the medical necessity of (A) mental health and substance use disorder benefits, and (B) medical and surgical benefits;

(2) A description of all nonquantitative treatment limitations that such health carrier applied to (A) mental health and substance use disorder benefits, and (B) medical and surgical benefits; and

(3) The results of an analysis concerning the processes, strategies, evidentiary standards and other factors that such health carrier used in developing and applying the criteria described in subdivision (1) of this subsection and each nonquantitative treatment limitation described in subdivision (2) of this subsection, provided the commissioner shall not disclose such results in a manner that is likely to compromise the financial, competitive or proprietary nature of such results. The results of such analysis shall, at a minimum:

(A) Disclose each factor that such health carrier considered, regardless of whether such health carrier rejected such factor, in (i) designing each nonquantitative treatment limitation described in subdivision (2) of this subsection, and (ii) determining whether to apply such nonquantitative treatment limitation;

(B) Disclose any and all evidentiary standards, which standards may be qualitative or quantitative in nature, applied under a factor described in subparagraph (A) of this subdivision, and, if no evidentiary standard is applied under such a factor, a clear description of such factor;

(C) Provide the comparative analyses, including the results of such analyses, performed to determine that the processes and strategies used to design each nonquantitative treatment limitation, as written, and the processes and strategies used to apply such nonquantitative treatment limitation, as written, to mental health and substance use disorder benefits are comparable to, and applied no more stringently than, the processes and strategies used to design each nonquantitative treatment limitation, as written, and the processes and strategies used to apply such nonquantitative treatment limitation, as written, to medical and surgical benefits;

(D) Provide the comparative analyses, including the results of such analyses, performed to determine that the processes and strategies used to apply each nonquantitative treatment limitation, in operation, to mental health and substance use disorder benefits are comparable to, and applied no more stringently than, the processes and strategies used to apply each nonquantitative treatment limitation, in operation, to medical and surgical benefits; and

(E) Disclose information that, in the opinion of the Insurance Commissioner, is sufficient to demonstrate that such health carrier, consistent with the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, P.L. 110-343, as amended from time to time, and regulations adopted thereunder, (i) applied each nonquantitative treatment limitation described in subdivision (2) of this subsection comparably, and not more stringently, to (I) mental health and substance use disorder benefits, and (II) medical and surgical benefits, and (ii) complied with (I) sections 38a-488c and 38a-514c, (II) sections 38a-488a and 38a-514, (III) sections 38a-510 and 38a-544, and (IV) the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, P.L. 110-343, as amended from time to time, and regulations adopted thereunder.

(c) (1) Not later than April 15, 2021, and annually thereafter, the Insurance Commissioner shall submit each report that the commissioner received pursuant to subsection (b) of this section for the calendar year immediately preceding to:

(A) The joint standing committee of the General Assembly having cognizance of matters relating to insurance, in accordance with section 11-4a; and

(B) The Attorney General, Healthcare Advocate and executive director of the Office of Health Strategy.

(2) Notwithstanding subdivision (1) of this subsection, the commissioner shall not submit the name or identity of any health carrier or entity that has contracted with such health carrier, and such name or identity shall be given confidential treatment and not be made public by the commissioner.

(d) Not later than May 15, 2021, and annually thereafter, the joint standing committee of the General Assembly having cognizance of matters relating to insurance may hold a public hearing concerning the reports that such committee received pursuant to subsection (c) of this section for the calendar year immediately preceding. The Insurance Commissioner, or the commissioner's designee, shall attend the public hearing and inform the committee whether, in the commissioner's opinion, each health carrier, for the calendar year immediately preceding, (1) submitted a report pursuant to subsection (b) of this section that satisfies the requirements established in said subsection, and (2) complied with (A) sections 38a-488c and 38a-514c, (B) sections 38a-488a and 38a-514, (C) sections 38a-510 and 38a-544, and (D) the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, P.L. 110-343, as amended from time to time, and regulations adopted thereunder.

(e) Nothing in this section shall be construed to require any disclosure in violation of (1) 42 USC 290dd-2, as amended from time to time, (2) 42 USC 1320d et seq., as amended from time to time, (3) 42 CFR 2, as amended from time to time, and (4) 45 CFR 160.101 to 164.534, inclusive, as amended from time to time.

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

(P.A. 19-159, S. 1.)

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Sec. 38a-477ff. Third-party discounts and payments for covered benefits. Credit required. (a) Each insurer, health care center, hospital service corporation, medical service corporation, fraternal benefit society or other entity that delivers, issues for delivery, renews, amends or continues an individual or group health insurance policy in this state on or after January 1, 2022, providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 shall, when calculating an insured's liability for a coinsurance, copayment, deductible or other out-of-pocket expense for a covered benefit, give credit for any discount provided or payment made by a third party for the amount of, or any portion of the amount of, the coinsurance, copayment, deductible or other out-of-pocket expense for the covered benefit.

(b) The provisions of subsection (a) of this section shall apply to a high deductible health plan, as that term is used in subsection (f) of section 38a-493 or subsection (f) of section 38a-520, as applicable, to the maximum extent permitted by federal law, except if such plan is used to establish a medical savings account or an Archer MSA pursuant to Section 220 of the Internal Revenue Code of 1986, or any subsequent corresponding internal revenue code of the United States, as amended from time to time, or a health savings account pursuant to Section 223 of said Internal Revenue Code, as amended from time to time, the provisions of said subsection (a) shall apply to such plan to the maximum extent that (1) is permitted by federal law, and (2) does not disqualify such account for the deduction allowed under said Section 220 or 223, as applicable.

(P.A. 21-14, S. 2; P.A. 22-146, S. 22.)

History: P.A. 21-14 effective January 1, 2022; P.A. 22-146 designated existing language as Subsec. (a) and added Subsec. (b) re applicability to high deductible health plans, effective May 7, 2022, and applicable to policies delivered, issued for delivery, renewed, amended or continued on or after January 1, 2022.

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Sec. 38a-477gg. Contracts between health carriers and pharmacy benefits managers. Credit required for third-party discounts and payments for covered prescription drug benefits. (a) On and after January 1, 2022, each contract entered into between a health carrier, as defined in section 38a-591a, and a pharmacy benefits manager, as defined in section 38a-479aaa, for the administration of the pharmacy benefit portion of a health benefit plan in this state on behalf of plan sponsors shall require that the pharmacy benefits manager, when calculating an insured's or enrollee's liability for a coinsurance, copayment, deductible or other out-of-pocket expense for a covered prescription drug benefit, give credit for any discount provided or payment made by a third party for the amount of, or any portion of the amount of, the coinsurance, copayment, deductible or other out-of-pocket expense for the covered prescription drug benefit.

(P.A. 21-14, S. 5; P.A. 22-146, S. 23.)

History: P.A. 21-14 effective January 1, 2022; P.A. 22-146 designated existing language as Subsec. (a) and added Subsec. (b) re applicability to high deductible health plans, effective May 7, 2022, and applicable to contracts entered into on or after January 1, 2022.

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Sec. 38a-477hh. Denial of coverage for otherwise covered benefits based on measurement of blood oxygen level by pulse oximeter prohibited. No insurer, health care center, hospital service corporation, medical service corporation, fraternal benefit society or other entity delivering, issuing for delivery, renewing, amending or continuing an individual or group health insurance policy in this state on or after January 1, 2022, providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 shall deny coverage for an otherwise covered benefit if such denial is exclusively based on an insured's blood oxygen level as measured by a pulse oximeter.

(P.A. 21-57, S. 2.)

History: P.A. 21-57 effective January 1, 2022.

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Sec. 38a-477ii. Pulse oximeter accuracy. Educational materials. Distribution and posting required. (a) For the purposes of this section:

(1) “Health carrier” has the same meaning as provided in section 38a-1080; and

(2) “Pharmacy benefits manager” has the same meaning as provided in section 38a-479aaa.

(b) Not later than July 1, 2022, the Insurance Department shall:

(1) Post the educational materials developed pursuant to subsection (b) of section 19a-133d on the department's Internet web site; and

(2) Distribute the educational materials developed pursuant to subsection (b) of section 19a-133d to each health carrier and pharmacy benefits manager doing business in this state.

(P.A. 21-57, S. 3.)

History: P.A. 21-57 effective July 1, 2021.

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Sec. 38a-477jj. Prescription drug formularies and lists of covered drugs. Removal or movement to higher cost-sharing tier during plan year prohibited. Exceptions. Study and report. (a) For the purposes of this section:

(1) “Affordable Care Act” has the same meaning as provided in section 38a-1080;

(2) “Exchange” has the same meaning as provided in section 38a-1080;

(3) “Health benefit plan” has the same meaning as provided in section 38a-1080, except that such term shall not include a grandfathered health plan as such term is used in the Affordable Care Act;

(4) “Health carrier” has the same meaning as provided in section 38a-1080;

(5) “Office of Health Strategy” means the Office of Health Strategy established under section 19a-754a; and

(6) “Qualified health plan” has the same meaning as provided in section 38a-1080.

(b) Notwithstanding any provision of the general statutes and except as provided in subsection (c) of this section, no health carrier offering a health benefit plan in this state on or after January 1, 2022, that includes a pharmacy benefit and uses a drug formulary or list of covered drugs may:

(1) Remove a prescription drug from the drug formulary or list of covered drugs during a plan year; or

(2) Move a prescription drug from a cost-sharing tier that imposes a lesser coinsurance, copayment or deductible for the prescription drug to a cost-sharing tier that imposes a greater coinsurance, copayment or deductible for the prescription drug during a plan year, unless the prescription drug is subject to an in-network coinsurance, copayment or deductible that is not greater than forty dollars per prescription per month in any tier.

(c) A health carrier offering a health benefit plan in this state on or after January 1, 2022, that includes a pharmacy benefit and uses a drug formulary or list of covered drugs may:

(1) Remove a prescription drug from the drug formulary or list of covered drugs, upon at least ninety days' advance notice to a covered person and the covered person's treating physician, if:

(A) The federal Food and Drug Administration issues an announcement, guidance, notice, warning or statement concerning the prescription drug that calls into question the clinical safety of the prescription drug, unless the covered person's treating physician states, in writing, that the prescription drug remains medically necessary despite such announcement, guidance, notice, warning or statement; or

(B) The prescription drug is approved by the federal Food and Drug Administration for use without a prescription; and

(2) Move a brand-name prescription drug from a cost-sharing tier that imposes a lesser coinsurance, copayment or deductible for the brand-name prescription drug to a cost-sharing tier that imposes a greater coinsurance, copayment or deductible for the brand-name prescription drug if the health carrier adds to the drug formulary or list of covered drugs a generic prescription drug that is:

(A) Approved by the federal Food and Drug Administration for use as an alternative to such brand-name prescription drug; and

(B) In a cost-sharing tier that imposes a coinsurance, copayment or deductible for the generic prescription drug that is lesser than the coinsurance, copayment or deductible that is imposed for such brand-name prescription drug.

(d) Nothing in this section shall prevent or prohibit a health carrier from adding a prescription drug to a formulary or list of covered drugs at any time.

(e) (1) The Office of Health Strategy shall, at least annually, conduct a study to determine the impact that the requirements established in subsections (a) to (d), inclusive, of this section have on the cost of health benefit plans offered, delivered, issued for delivery, renewed, amended or continued in this state and qualified health plans offered and sold through the exchange.

(2) Not later than January 31, 2023, and annually thereafter, the Office of Health Strategy shall submit a report, in accordance with the provisions of section 11-4a, to the commissioner and the joint standing committee of the General Assembly having cognizance of matters relating to insurance. Such report shall disclose the results of the study conducted pursuant to subdivision (1) of this subsection for the preceding year.

(P.A. 21-96, S. 2.)

History: P.A. 21-96 effective January 1, 2022.

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Sec. 38a-477kk. Proof of coverage to disclose whether coverage is fully insured or self-insured. Regulations. (a) For the purposes of this section:

(1) “Health carrier” has the same meaning as provided in section 38a-1080; and

(2) “Third-party administrator” has the same meaning as provided in section 38a-720.

(b) Each health carrier or third-party administrator that issues a card to an individual in this state for the purpose of enabling such individual to prove that such individual has health coverage shall include in such card a statement disclosing whether such coverage is fully insured or self-insured. Such statement shall be prominently displayed on such card in a readily understandable, standardized form prescribed by the Insurance Commissioner.

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

(June Sp. Sess. P.A. 21-2, S. 313.)

History: June Sp. Sess. P.A. 21-2 effective January 1, 2022.

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Sec. 38a-477ll. Coverage for health enhancement programs. (a) For the purposes of this section, “health enhancement program” means a health benefit program that ensures access and removes barriers to essential, high-value clinical services.

(b) (1) Not later than January 1, 2024, each insurer, health care center, hospital service corporation, medical service corporation, fraternal benefit society or other entity that delivers, issues for delivery, renews, amends or continues in this state an individual or group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 shall develop not less than two health enhancement programs under such policy.

(2) Each health enhancement program developed pursuant to subdivision (1) of this subsection shall:

(A) Be available to each insured under the individual or group health insurance policy; and

(B) Provide to each insured under the individual or group health insurance policy incentives that are directly related to the provision of health insurance coverage, provided such insured chooses to complete certain preventive examinations and screenings recommended by the United States Preventive Services Task Force with a rating of “A” or “B”.

(3) No health enhancement program developed pursuant to subdivision (1) of this subsection shall impose any penalty or other negative incentive on an insured under the individual or group health insurance policy nor shall any insured be required to participate in a health enhancement program.

(c) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall include coverage for the health enhancement programs that the insurer, health care center, hospital service corporation, medical service corporation, fraternal benefit society or other entity that delivered, issued, renewed, amended or continued such policy developed pursuant to this section.

(d) 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 shall include coverage for the health enhancement programs that the insurer, health care center, hospital service corporation, medical service corporation, fraternal benefit society or other entity that delivered, issued, renewed, amended or continued such policy developed pursuant to this section.

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

(P.A. 22-118, S. 224.)

History: P.A. 22-118 effective January 1, 2023.

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PART Ia

HEALTH INSURANCE: MANAGED CARE

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

(1) “Commissioner” means the Insurance Commissioner.

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

(3) “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.

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

(5) “Managed care organization” means an insurer, health care center, hospital service corporation, 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.

(6) “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, as defined in section 38a-591a.

(7) “Preferred provider network” has the same meaning as provided in section 38a-479aa.

(8) “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.

(9) “Utilization review” has the same meaning as provided in section 38a-591a.

(10) “Utilization review company” has the same meaning as provided in section 38a-591a.

(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; P.A. 11-58, S. 67; P.A. 15-118, S. 3; P.A. 21-14, S. 3.)

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; P.A. 11-58 deleted former Subdivs. (1) and (10) re definitions of “adverse determination” and “review entity”, replaced references to Sec. 38a-226 with references to Sec. 38a-591a and made conforming and technical changes, effective July 1, 2011; P.A. 15-118 made a technical change in Subdiv. (5); P.A. 21-14 amended introductory language to add reference to Sec. 38a-478w and make a conforming change, effective January 1, 2022.

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Sec. 38a-478a. Commissioner's report to the Governor and the General Assembly. On March first annually, the Insurance Commissioner shall submit a report to the Governor and to the joint standing committees of the General Assembly having cognizance of matters relating to public health and insurance, concerning the commissioner's responsibilities under the provisions of sections 38a-478 to 38a-478u, inclusive, 38a-479aa, 38a-591a to 38a-591h, inclusive, and 38a-993. The report shall include: (1) A summary of the quality assurance plans submitted by managed care organizations pursuant to section 38a-478c along with suggested changes to improve such plans; (2) suggested modifications to the consumer report card developed under the provisions of section 38a-478l; (3) a summary of the commissioner's procedures and activities in conducting market conduct examinations of utilization review companies and preferred provider networks, including, but not limited to: (A) The number of desk and field audits completed during the previous calendar year; (B) a summary of findings of the desk and field audits, including any recommendations made for improvements or modifications; (C) a description of complaints concerning managed care companies, and any preferred provider network that provides services to enrollees on behalf of the managed care organization, including a summary and analysis of any trends or similarities found in the managed care complaints filed by enrollees; (4) a summary of the complaints concerning managed care organizations received by the Insurance Department's Consumer Affairs Division and the commissioner under section 38a-591g, including a summary and analysis of any trends or similarities found in the complaints received; (5) a summary of any violations the commissioner has found against any managed care organization or any preferred provider network that provides services to enrollees on behalf of the managed care organization; and (6) a summary of the issues discussed related to health care or managed care organizations at the Insurance Department's quarterly forums throughout the state.

(P.A. 97-99, S. 2; June 18 Sp. Sess. P.A. 97-8, S. 57, 88; P.A. 99-284, S. 51, 60; P.A. 00-196, S. 22; June Sp. Sess. P.A. 01-4, S. 23; P.A. 03-169, S. 11; P.A. 11-58, S. 70.)

History: June 18 Sp. Sess. P.A. 97-8 changed reporting date from January 15, 1999, to March 1, 1999, and in Subdiv. (3)(C) changed “complaints” to “managed care complaints”, effective July 1, 1997; P.A. 99-284 deleted obsolete reference to Sec. 38a-514a, effective January 1, 2000; P.A. 00-196 made a technical change; June Sp. Sess. P.A. 01-4 replaced reference to Sec. 19a-647 with reference to Sec. 38a-479aa; P.A. 03-169 added provisions re preferred provider networks in Subdivs. (3) and (5); P.A. 11-58 replaced references to Secs. 38a-226 to 38a-226d and 38a-478n with “sections 38a-591a to 38a-591h, inclusive,” and “section 38a-591g”, respectively, added “concerning managed care organizations” in Subdiv. (4), and made technical changes, effective July 1, 2011.

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Sec. 38a-478b. Penalty for managed care organization's failure to file data and reports. Commissioner's report to the Governor and the General Assembly on organizations that fail to file data and reports. (a) Each managed care organization, as defined in section 38a-478, that fails to file the data, reports or information required by sections 38a-478 to 38a-478u, inclusive, 38a-479aa, 38a-591a to 38a-591h, inclusive, and 38a-993 shall pay a late fee of one hundred dollars per day for each day from the due date of such data, reports or information to the date of filing. Each managed care organization that files incomplete data, reports or information shall be so informed by the commissioner, shall be given a date by which to remedy such incomplete filing and shall pay said late fee commencing from the new due date.

(b) On June first annually, the commissioner shall submit to the Governor and to the joint standing committees of the General Assembly having cognizance of matters relating to public health and insurance, a list of those managed care organizations that have failed to file any data, report or information required by sections 38a-478 to 38a-478u, inclusive, 38a-479aa, 38a-591a to 38a-591h, inclusive, and 38a-993.

(P.A. 97-99, S. 3; P.A. 99-284, S. 52, 60; P.A. 00-196, S. 23; June Sp. Sess. P.A. 01-4, S. 24; P.A. 11-58, S. 71.)

History: P.A. 99-284 deleted obsolete references to Sec. 38a-514a, effective January 1, 2000; P.A. 00-196 made a technical change in Subsec. (b); June Sp. Sess. P.A. 01-4 replaced references to Sec. 19a-647 with references to Sec. 38a-479aa; P.A. 11-58 replaced references to Secs. 38a-226 to 38a-226d with “sections 38a-591a to 38a-591h, inclusive,” and made technical changes, effective July 1, 2011.

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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 first of each year, all data required by the National Committee for Quality Assurance for its Health Plan Employer Data and Information Set. 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 subsection, including any change in a plan's rates over the prior three years, its state medical loss ratio and its federal medical loss ratio, as both terms are defined in 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 specialty care provider, the percentage of primary and specialty 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; and

(6) A report on claims denial data for lives covered in the state for the prior calendar year, in a format prescribed by the commissioner, that includes: (A) The total number of claims received; (B) the total number of claims denied; (C) the total number of denials that were appealed; (D) the total number of denials that were reversed upon appeal; (E) (i) the reasons for the denials, including, but not limited to, “not a covered benefit”, “not medically necessary” and “not an eligible enrollee”, (ii) the total number of times each reason was used, and (iii) the percentage of the total number of denials each reason was used; and (F) other information the commissioner deems necessary.

(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).

(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.

(e) The information required under subdivision (6) of subsection (a) of this section shall be posted on the Insurance Department's Internet web site.

(P.A. 97-99, S. 4; P.A. 98-27, S. 19; P.A. 03-169, S. 12; P.A. 09-46, S. 3; P.A. 10-5, S. 16; 10-19, S. 1; P.A. 11-58, S. 51; P.A. 15-118, S. 45, 46.)

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); P.A. 10-5 made a technical change in Subsec. (a)(1), effective May 5, 2010; P.A. 10-19 made a technical change in Subsec. (a)(1), added Subsec. (a)(6) re report on claims denial data and added Subsec. (e) re posting of data on Insurance Department's web site, effective July 1, 2010; P.A. 11-58 amended Subsec. (a) to add federal medical loss ratio to information provided to commissioner to complete consumer report card in Subdiv. (4) and to make technical changes, effective January 1, 2012; P.A. 15-118 made technical changes in Subsec. (a)(1) and (4).

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Sec. 38a-478d. Provider directory. Notification to enrollee of termination or withdrawal of enrollee's primary care provider. For any contract delivered, issued for delivery, renewed, amended or continued in this state, each managed care organization shall:

(1) Provide at least annually to each enrollee a provider directory that conforms to the requirements of section 38a-477h. Such directory shall include, under a separate category or heading, participating advanced practice registered nurses; and

(2) For a managed care plan that requires the selection of a primary care provider:

(A) Allow an enrollee to designate a participating, in-network physician or a participating, in-network advanced practice registered nurse as such enrollee's primary care provider; and

(B) Provide notification in accordance with subsection (g) of section 38a-472f to each such enrollee upon the termination or withdrawal of the enrollee's primary care provider.

(P.A. 97-99, S. 5; P.A. 07-18, S. 1; P.A. 11-199, S. 1; P.A. 16-205, S. 6.)

History: P.A. 07-18 amended Subdiv. (1) to require that list of providers be given in writing or through the Internet at the option of enrollee and amended Subdiv. (2) to limit notification to enrollee in a managed care plan that requires selection of a primary care physician; P.A. 11-199 substantially revised section to require managed care organizations to include in their provider listings advanced practice registered nurses under a separate category or heading and to allow enrollees to designate a participating, in-network physician or a participating, in-network advanced practice registered nurse as such enrollee's primary care provider; P.A. 16-205 deleted former Subdiv. (1) re listing of providers, redesignated existing Subdiv. (2) as Subdiv. (1) and amended same by adding provision re provider directory and making a conforming change, and redesignated existing Subdiv. (3) re managed care plan as Subdiv. (2) and amended same by replacing “, as soon as possible” with reference to Sec. 38a-472f(g) in Subpara. (B), effective January 1, 2017.

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

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

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

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

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

(P.A. 97-99, S. 7.)

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Sec. 38a-478g. Managed care contract requirements. Plan description requirements. (a) Each managed care contract delivered, issued for delivery, renewed, amended or continued in this state 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) extension of benefits, if any; (10) subrogation, if any; (11) description of the service area, and out-of-area benefits and services, if any; (12) 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; (13) a statement that the contract includes the endorsement thereon and attached papers, if any, and contains the entire contract; (14) 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 (15) 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 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) Prior authorization and utilization review requirements and procedures, internal grievance procedures and internal and external complaint procedures;

(9) The state medical loss ratio and the federal medical loss ratio, as both terms are defined in 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 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; P.A. 11-58, S. 52; P.A. 12-145, S. 10; P.A. 15-118, S. 47; 15-247, S. 9; P.A. 17-15, S. 46.)

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; P.A. 11-58 amended Subsec. (b)(9) to add federal medical loss ratio to information contained in plan description and make conforming changes, effective January 1, 2012; P.A. 12-145 made a technical change in Subsec. (b)(3), effective June 15, 2012; P.A. 15-118 made a technical change in Subsec. (b)(14); P.A. 15-247 amended Subsec. (a) to delete former Subdiv. (9) re conversion and redesignate existing Subdivs. (10) to (16) as Subdivs. (9) to (15), effective July 10, 2015; P.A. 17-15 made a technical change in Subsec. (b)(8).

See Sec. 38a-477g re contracts between health carriers and participating providers.

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Sec. 38a-478h. Contract requirements and notice for removal or departure of provider. Retaliatory action prohibited. (a) Each contract delivered, issued for delivery, renewed, amended or continued in this state between a managed care organization and a participating provider shall conform to the requirements of section 38a-477g and shall include notice provisions for the removal or departure of such provider in accordance with subsection (g) of section 38a-472f.

(b) No managed care organization shall take or threaten to take any action against any provider in retaliation for such provider's assistance to an enrollee under the provisions of section 38a-591g.

(P.A. 97-99, S. 9; P.A. 11-58, S. 72; P.A. 16-205, S. 7.)

History: P.A. 11-58 made a technical change in Subsec. (a) and replaced references to Secs. 38a-226c(e) and 38a-478n with “section 38a-591g” in Subsec. (c), effective July 1, 2011; P.A. 16-205 amended Subsec. (a) by replacing provisions re advance written notice for withdrawal or termination of agreement with provisions re requirements of Sec. 38a-477g and notice provisions of Sec. 38a-472f(g), deleted former Subsec. (b) re exceptions and redesignated existing Subsec. (c) re managed care organization taking action against provider as Subsec. (b), effective January 1, 2017.

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Sec. 38a-478i. Limitation on enrollee rights prohibited. No contract delivered, issued for delivery, renewed, amended or continued in this state between a managed care organization and a participating provider shall prohibit or limit any cause of action or contract rights an enrollee otherwise has.

(P.A. 97-99, S. 10; P.A. 12-145, S. 41.)

History: P.A. 12-145 deleted “on and after October 1, 1997,”, effective June 15, 2012.

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

(P.A. 97-99, S. 11; June 18 Sp. Sess. P.A. 97-8, S. 59, 88; P.A. 19-117, S. 239.)

History: June 18 Sp. Sess. P.A. 97-8 added exception re laws of a foreign state, effective July 1, 1997; P.A. 19-117 added references to deductible and added “or a subcontractor of such managed care organization”, effective January 1, 2020.

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Sec. 38a-478k. Gag clauses prohibited. (a) No contract delivered, issued for delivery, renewed, amended or continued in this state between a managed care organization and a participating provider shall prohibit the provider from discussing with an enrollee any treatment options and services available in or out of network, including experimental treatments.

(b) No contract delivered, issued for delivery, renewed, amended or continued in this state between a managed care organization and a participating provider shall prohibit the provider from disclosing, to an enrollee who inquires, the method the managed care organization uses to compensate the provider.

(P.A. 97-99, S. 12; P.A. 12-145, S. 42.)

History: P.A. 12-145 deleted “on and after October 1, 1997,”, effective June 15, 2012.

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Sec. 38a-478l. Consumer report card required. Content. Data analysis by commissioner. (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) (1) The consumer report card shall be known as the “Consumer Report Card on Health Insurance Carriers in Connecticut” and shall include (A) all health care centers licensed pursuant to chapter 698a, (B) the fifteen largest licensed health insurers that use provider networks and that are not included in subparagraph (A) of this subdivision, (C) the state medical loss ratio of each such health care center or licensed health insurer, (D) the federal medical loss ratio of each such health care center or licensed health insurer, (E) the information required under subdivision (6) of subsection (a) of section 38a-478c, and (F) information concerning mental health services, as specified in subsection (c) of this section. The insurers selected pursuant to subparagraph (B) of this subdivision shall be selected on the basis of Connecticut direct written health premiums from such network plans.

(2) For the purposes of this section and sections 38a-477c, 38a-478c and 38a-478g:

(A) “State 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;

(B) “Federal medical loss ratio” has the same meaning as provided in, and shall be calculated in accordance with, the Patient Protection and Affordable Care Act, P.L. 111-148, as amended from time to time, and regulations adopted thereunder.

(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 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.

(e) The commissioner shall analyze annually the data submitted under subparagraphs (E) and (F) of subdivision (1) of subsection (b) of this section for the accuracy of, trends in and statistically significant differences in such data among the health care centers and licensed health insurers included in the consumer report card. The commissioner may investigate any such differences to determine whether further action by the commissioner is warranted.

(P.A. 97-99, S. 13; P.A. 06-188, S. 34; P.A. 07-217, S. 156; P.A. 09-46, S. 1; P.A. 10-19, S. 2; P.A. 11-58, S. 49; P.A. 13-3, S. 78; P.A. 15-118, S. 48.)

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; P.A. 10-19 amended Subsec. (b) to add new Subdiv. (4) re information required under Sec. 38a-478c(a)(6) and redesignate existing Subdiv. (4) as Subdiv. (5), effective January 1, 2011; P.A. 11-58 amended Subsec. (b) to add requirement to include federal medical loss ratio in consumer report card, add definition of federal medical loss ratio and make conforming and technical changes, effective January 1, 2012; P.A. 13-3 added Subsec. (e) re data analysis by commissioner; P.A. 15-118 made a technical change in Subsec. (c).

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(P.A. 97-99, S. 14, 20; June 18 Sp. Sess. P.A. 97-8, S. 60, 88; P.A. 99-284, S. 14, 35, 60; P.A. 03-278, S. 94; P.A. 04-157, S. 1; P.A. 05-29, S. 1; 05-94, S. 2, 3; 05-97, S. 1; 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; P.A. 11-58, S. 89.)

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

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

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

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

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Sec. 38a-478p. Expedited utilization review. Standardized process required. Section 38a-478p is repealed, effective July 1, 2011.

(P.A. 97-99, S. 22, 32; P.A. 11-58, S. 89.)

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

(P.A. 97-99, S. 25.)

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

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

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

(d) The Insurance Commissioner may develop and disseminate to hospitals in this state a claims form system that will ensure that all hospitals consistently code for the presenting and diagnosis symptoms on all emergency claims.

(e) Each 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 shall provide coverage for health care services that are medically necessary, as defined in section 38a-482a or 38a-513c, as applicable, for an emergency medical condition described in subsection (c) of this section.

(P.A. 97-99, S. 26; June 18 Sp. Sess. P.A. 97-8, S. 61, 88; P.A. 11-58, S. 73; P.A. 15-118, S. 49; P.A. 19-117, S. 246.)

History: June 18 Sp. Sess. P.A. 97-8 amended Subsec. (b) to add provision re “the final diagnosis, whichever reasonably indicates an emergency medical condition,” effective July 1, 1997; P.A. 11-58 amended Subsec. (d) to delete provision re consultation with working group convened pursuant to Sec. 38a-478p, effective July 1, 2011; P.A. 15-118 made a technical change in Subsec. (c); P.A. 19-117 added Subsec. (e) re coverage for medically necessary health care services for emergency medical conditions, effective January 1, 2020.

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Sec. 38a-478s. Nonapplicability to self-insured employee welfare benefit plans and workers' compensation plans. (a) Nothing in sections 38a-478 to 38a-478o, inclusive, sections 38a-591a to 38a-591h, inclusive, or section 38a-591n shall be construed to apply to the arrangements of managed care organizations or health insurers offered to individuals covered under self-insured employee welfare benefit plans established pursuant to the federal Employee Retirement Income Security Act of 1974.

(b) The provisions of sections 38a-478 to 38a-478o, inclusive, sections 38a-591a to 38a-591h, inclusive, and section 38a-591n shall not apply to any plan that provides for the financing or delivery of health care services solely for the purposes of workers' compensation benefits pursuant to chapter 568.

(P.A. 97-99, S. 28, 30; June 18 Sp. Sess. P.A. 97-8, S. 64, 88; P.A. 99-284, S. 53, 60; P.A. 05-94, S. 4; P.A. 06-54, S. 5; P.A. 11-58, S. 74; P.A. 12-102, S. 9.)

History: June 18 Sp. Sess. P.A. 97-8 amended Subsec. (a) by replacing the exemption for managed care organizations with an exemption for the arrangements of managed care organizations offered to individuals covered under self-insured plans, effective July 1, 1997; P.A. 99-284 deleted obsolete reference to Sec. 38a-514a from Subsec. (b), effective January 1, 2000; P.A. 05-94 deleted references to “managed care organizations” and “employee welfare benefit plans established pursuant to the federal Employee Retirement Income Security Act of 1974”, and referenced “health plans” in Subsec. (a), effective July 1, 2005; P.A. 06-54 amended Subsec. (a) to insert “of managed care organizations or health insurers” and to substitute “self-insured employee welfare benefit plans established pursuant to the federal Employee Retirement Income Security Act of 1974” for “self-insured health plans”, effective May 8, 2006; P.A. 11-58 added references to Secs. 38a-591a to 38a-591h, effective July 1, 2011; P.A. 12-102 added references to Sec. 38a-591n.

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Sec. 38a-478t. Commissioner of Public Health to receive data. The Commissioner of Public Health may request and shall receive any data, report or information filed with the Insurance Commissioner pursuant to the provisions of sections 38a-478 to 38a-478u, inclusive, 38a-479aa, 38a-591j, 38a-591k and 38a-993.

(P.A. 97-99, S. 31; P.A. 99-284, S. 54, 60; June Sp. Sess. P.A. 01-4, S. 25; P.A. 11-58, S. 75.)

History: P.A. 99-284 deleted obsolete reference to Sec. 38a-514a, effective January 1, 2000; June Sp. Sess. P.A. 01-4 replaced reference to Sec. 19a-647 with reference to Sec. 38a-479aa; P.A. 11-58 replaced reference to Secs. 38a-226 to 38a-226d with reference to Secs. 38a-591j and 38a-591k, effective July 1, 2011.

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

(P.A. 97-99, S. 29; P.A. 99-284, S. 55, 60; June Sp. Sess. P.A. 01-4, S. 26; P.A. 03-199, S. 5; P.A. 11-58, S. 76.)

History: P.A. 99-284 deleted obsolete reference to Sec. 38a-514a, effective January 1, 2000; June Sp. Sess. P.A. 01-4 replaced reference to Sec. 19a-647 with reference to Sec. 38a-479aa; P.A. 03-199 substituted “may adopt” for “shall adopt” re regulations; P.A. 11-58 deleted reference to Secs. 38a-226 to 38a-226d, effective July 1, 2011.

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

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

(P.A. 99-284, S. 31.)

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Sec. 38a-478w. Managed care organization's calculation of enrollee liability for covered benefits. Credit required for third-party discounts and payments. (a) For any contract delivered, issued for delivery, renewed, amended or continued in this state on or after January 1, 2022, each managed care organization shall, when calculating an enrollee's liability for a coinsurance, copayment, deductible or other out-of-pocket expense for a covered benefit, give credit for any discount provided or payment made by a third party for the amount of, or any portion of the amount of, the coinsurance, copayment, deductible or other out-of-pocket expense for the covered benefit.

(P.A. 21-14, S. 4; P.A. 22-146, S. 24.)

History: P.A. 21-14 effective January 1, 2022; P.A. 22-146 designated existing language as Subsec. (a) and added Subsec. (b) re applicability to high deductible health plans, effective May 7, 2022, and applicable to contracts delivered, issued for delivery, renewed, amended or continued on or after January 1, 2022.

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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, dentist, naturopath 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 enrollees' 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 or, upon request, current dental terminology (CDT) codes, (B) the Health Care Procedure Coding System (HCPCS) codes applicable to such provider, and (C) such CPT codes, CDT 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 (CPT) or current dental terminology (CDT) 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; P.A. 11-132, S. 1; P.A. 19-155, 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; P.A. 11-132 made a technical change in Subsec. (a)(2); P.A. 19-155 amended Subsec. (a)(2) by redefining “provider” and amended Subsecs. (b)(1) and (c) by adding references to current dental terminology codes, effective January 1, 2020.

See Sec. 38a-193 for additional provisions re contracts between health care centers and participating providers.

See Secs. 42-490 to 42-493, inclusive, for provisions re the selling, leasing, renting, assigning or granting of access to a contract or terms of a contract between health care providers and contracting entities.

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Sec. 38a-479a. Physicians and managed care organizations to discuss issues relative to contracting between such parties. The chairpersons and ranking members of the joint standing committee of the General Assembly having cognizance of matters relating to insurance shall convene, at least two times each year, a group of physicians and managed care organizations, to discuss issues relative to contracting between physicians and managed care organizations, including issues relative to any national settlement agreements, to the extent permitted under such settlement agreements.

(P.A. 06-178, S. 2.)

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Sec. 38a-479b. Material changes to fee schedules. Return of payment by provider. Appeals. Filing of claim by provider under other applicable insurance coverage. Certain clauses, covenants and agreements prohibited. Exception. (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) Notwithstanding subsection (a) of this section, a contracting health organization may introduce a new insurance product to a provider at any time, provided such provider is given at least sixty days' advance notice by mail, electronic mail or facsimile by such organization if the introduction of such insurance product will make material changes to the provider's administrative requirements under the participating provider contract or to the provider's fee schedule. The provider may decline to participate in such new product by providing notice to the contracting health organization as set forth in the advance notice, which shall include a period of not less than thirty days for a provider to decline, or in accordance with the time frames under the applicable terms of such provider's participating provider contract.

(c) (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;

(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.

(d) Except as provided in subsection (e) of this section, no contracting health organization shall include in any participating provider contract or contract with a hospital licensed under chapter 368v, that is entered into, renewed or amended on or after October 1, 2011, or contract offered to a provider or hospital on or after October 1, 2011, any clause, covenant or agreement that:

(1) Requires the provider or hospital to:

(A) Disclose to the contracting health organization the provider's or hospital's payment or reimbursement rates from any other contracting health organization the provider or hospital has contracted, or may contract, with;

(B) Provide services or procedures to the contracting health organization at a payment or reimbursement rate equal to or lower than the lowest of such rates the provider or hospital has contracted, or may contract, with any other contracting health organization;

(C) Certify to the contracting health organization that the provider or hospital has not contracted with any other contracting health organization to provide services or procedures at a payment or reimbursement rate lower than the rates contracted for with the contracting health organization;

(2) Prohibits or limits the provider or hospital from contracting with any other contracting health organization to provide services or procedures at a payment or reimbursement rate lower than the rates contracted for with the contracting health organization; or

(3) Allows the contracting health organization to terminate or renegotiate a contract with the provider or hospital prior to renewal if the provider or hospital contracts with any other contracting health organization to provide services or procedures at a lower payment or reimbursement rate than the rates contracted for with the contracting health organization.

(e) (1) If a contract described in subsection (d) of this section is in effect prior to October 1, 2011, and includes a clause, covenant or agreement set forth under subdivisions (1) to (3), inclusive, of said subsection (d), such clause, covenant or agreement shall be void and unenforceable on the date such contract is next renewed or on January 1, 2014, whichever is earlier. Such invalidity shall not affect other provisions of such contract.

(2) Nothing in subdivision (1) of this subsection shall be construed to affect the rights of a contracting health organization to enforce such clause, covenant or agreement prior to the invalidation of such clause, covenant or agreement.

(P.A. 09-204, S. 2; P.A. 11-58, S. 16; 11-132, S. 2; P.A. 19-155, S. 2.)

History: P.A. 09-204 effective July 1, 2010; P.A. 11-58 added new Subsec. (b) re introduction of new insurance products, and redesignated existing Subsec. (b) as Subsec. (c), effective January 1, 2012; P.A. 11-132 added provisions, codified by the Revisors as Subsec. (d), prohibiting certain clauses, covenants or agreements in contracts between contracting health organizations and health care providers and hospitals, and added provisions, codified by the Revisors as Subsec. (e), re exception; P.A. 19-155 amended Subsec. (d) by deleting references to dentists, effective January 1, 2020.

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

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PART Ib

HEALTH INSURANCE: PREFERRED PROVIDER NETWORKS

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

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

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

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

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

(5) “Managed care plan” has the same meaning as provided in section 38a-478;

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

(7) “Preferred provider network” means a person that is not a managed care organization, but that pays claims for the delivery of health care services, accepts financial risk for the delivery of health care services and establishes, operates or maintains an arrangement or contract with providers relating to (A) the health care services rendered by the providers, and (B) the amounts to be paid to the providers for such services. “Preferred provider network” does not include (i) a workers' compensation preferred provider organization established pursuant to section 31-279-10 of the regulations of Connecticut state agencies, (ii) an independent practice association or physician hospital organization whose primary function is to contract with insurers and provide services to providers, (iii) a clinical laboratory, licensed pursuant to section 19a-565, whose primary payments for any contracted or referred services are made to other licensed clinical laboratories or for associated pathology services, or (iv) a pharmacy benefits manager responsible for administering pharmacy claims whose primary function is to administer the pharmacy benefit on behalf of a health benefit plan;

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

(9) “Commissioner” means the Insurance Commissioner.

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

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

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

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

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

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

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

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

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

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

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

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

(m) Each utilization review determination made by or on behalf of a preferred provider network shall be made in accordance with section 38a-591d.

(n) The requirements of subsections (h) and (i) of this section shall not apply to a consortium of federally qualified health centers funded by the state, providing services only to recipients of programs administered by the Department of Social Services.

(June Sp. Sess. P.A. 01-4, S. 21; P.A. 03-169, S. 1; P.A. 06-90, S. 1; 06-196, S. 294; P.A. 07-191, S. 1; 07-200, S. 10; P.A. 08-147, S. 14; 08-184, S. 43; P.A. 11-58, S. 77; P.A. 17-198, S. 10; P.A. 21-148, S. 6.)

History: P.A. 03-169 amended Subsec. (a) to substantially revise definitions, amended Subsec. (b) to require licensure before May 1, 2004, or May 1, 2005, for certain activities and to revise filing requirements, amended Subsec. (d) to make technical changes, amended Subsec. (e) to allow the commissioner to inspect books and records, and added new Subsecs. (f) to (m), inclusive, re requirements for preferred provider networks; P.A. 06-90 amended Subsec. (a)(7) to insert clause designators in exclusion from definition of “preferred provider network” and to include in such exclusion, clause (iii) re private clinical laboratory licensed under Sec. 19a-30 whose primary payments for services are made to other licensed clinical laboratories or for associated pathology services, effective May 30, 2006; P.A. 06-196 amended Subsec. (a)(7) by deleting “private” re licensed clinical laboratory in clause (iii), effective June 7, 2006; P.A. 07-191 amended Subsec. (i)(1) to provide that outstanding amount be at least equal to greater of an amount sufficient to make payments to participating providers for two months determined on basis of the two months within past year with greatest amounts owed to providers, rather than two “quarters”, effective July 1, 2007; P.A. 07-200 amended Subsec. (a)(7) to insert as exclusion from definition of “preferred provider network” clause (iv) re pharmacy benefits manager responsible for administering pharmacy claims whose primary function is to administer pharmacy benefit on behalf of a health benefit plan, effective January 1, 2008; P.A. 08-147 and P.A. 08-184 added Subsec. (n) exempting certain federally qualified health centers from requirements of Subsecs. (h) and (i) and requiring Commissioner of Social Services to adopt regulations re criteria to certify such federally qualified health centers, effective June 12, 2008; P.A. 11-58 amended Subsec. (m) to replace reference to Secs. 38a-226 to 38a-226d with “section 38a-591d” and delete provisions re appeals, effective July 1, 2011; P.A. 17-198 amended Subsec. (b) by deleting references to May 1, 2004 and May 1, 2005, added provision re license to be issued or renewed annually on July first, and replaced “March first” with “May first” re submitting applications, amended Subsec. (h)(1)(A) to replace $250,000 with $500,000, amended Subsec. (i)(1) by replacing “two months” with “four months”, and made technical and conforming changes, effective July 1, 2017; P.A. 21-148 amended Subsec. (n) by deleting provision re Commissioner of Social Services adopt regulations re certification of federally qualified health centers, effective July 1, 2021.

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

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

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

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

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

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

(4) Any other information the commissioner may require.

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

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

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

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

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

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

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

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

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

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

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

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

(12) A provision that the preferred provider network shall ensure that utilization review determinations are made in accordance with section 38a-591d.

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

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

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

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

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

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

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

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

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

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

(P.A. 03-169, S. 2; P.A. 07-217, S. 157; P.A. 11-58, S. 78.)

History: P.A. 03-169 effective May 1, 2004; P.A. 07-217 made technical changes in Subsec. (1)(2), effective July 12, 2007; P.A. 11-58 amended Subsec. (d)(12) to replace reference to Secs. 38a-226 to 38a-226d with “section 38a-591d” and delete provisions re appeals, effective July 1, 2011.

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

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

(P.A. 03-169, S. 3; P.A. 06-196, S. 164.)

History: P.A. 06-196 made a technical change in Subsec. (a), effective June 7, 2006.

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

(P.A. 03-169, S. 4.)

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

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

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

(P.A. 03-169, S. 5; P.A. 05-102, S. 6; P.A. 11-58, S. 79.)

History: P.A. 05-102 amended Subsec. (c) by renaming the Office of Managed Care Ombudsman the Office of the Healthcare Advocate and making conforming changes; P.A. 11-58 deleted references to Secs. 38a-226 to 38a-226d, effective July 1, 2011.

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Sec. 38a-479ff. Adverse action or threat of adverse action against complainant prohibited. Exception. Civil actions by aggrieved persons. No health insurer, health care center, utilization review company, as defined in section 38a-591a, or preferred provider network, as defined in section 38a-479aa, shall take or threaten to take any adverse personnel or coverage-related action against any enrollee, provider or employee in retaliation for such enrollee, provider or employee (1) filing a complaint with the Insurance Commissioner or the Office of the Healthcare Advocate, or (2) disclosing information to the Insurance Commissioner concerning any violation of this part or sections 38a-815 to 38a-819, inclusive, unless such disclosure violates the provisions of chapter 705 or the privacy provisions of the federal Health Insurance Portability and Accountability Act of 1996, P.L. 104-191, as amended from time to time, or regulations adopted thereunder. Any enrollee, provider or employee who is aggrieved by a violation of this section may bring a civil action in the Superior Court to recover damages and attorneys' fees and costs.

(P.A. 03-169, S. 6; P. A. 05-102, S. 7; P.A. 11-58, S. 80.)

History: P.A. 05-102 renamed the Office of Managed Care Ombudsman the Office of the Healthcare Advocate; P.A. 11-58 replaced reference to Sec. 38a-226 with “section 38a-591a”, deleted reference to Secs. 38a-226 to 38a-226d and made a technical change, effective July 1, 2011.

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

(P.A. 03-169, S. 7.)

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Secs. 38a-479hh to 38a-479pp. Reserved for future use.

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PART Ic

HEALTH INSURANCE: MEDICAL DISCOUNT PLANS

Sec. 38a-479qq. Medical discount plans: Definitions, prohibited sales practices, penalties. (a) As used in this section and section 38a-479rr:

(1) “Affiliate” means a person that directly or indirectly through one or more intermediaries, controls, or is controlled by, or is under common control with, a health insurer, health care center, hospital service corporation, medical service corporation or fraternal benefit society licensed in this state;

(2) “Consumer” means: (A) A person to whom a medical discount plan is marketed or advertised, or (B) a member, as defined in this subsection;

(3) “Marketer” means a person that markets, advertises or sells a medical discount plan, including, but not limited to, an entity that markets, advertises or sells a medical discount plan under its own name;

(4) “Medical discount plan” means a business arrangement or contract in which a person, in exchange for payment, provides access for its members to providers of health care services and the right to receive health care services from those providers at a discount. “Medical discount plan” does not include a product that (A) is otherwise subject to regulation or approval under this title, or (B) costs less than twenty-five dollars, annually, in the aggregate;

(5) “Medical discount plan organization” means a person that (A) establishes a medical discount plan, (B) contracts with providers, provider networks or other medical discount plan organizations to provide health care services at a discount to medical discount plan members, and (C) determines the fees charged to the members for the medical discount plan. “Medical discount plan organization” does not include a health insurer, health care center, hospital service corporation, medical service corporation or fraternal benefit society licensed in this state or any affiliate of such health insurer, health care center, hospital service corporation, medical service corporation or fraternal benefit society;

(6) “Health care services” means any care, service or treatment of an illness or dysfunction of, or injury to, the human body. “Health care services” includes physician care, inpatient care, hospital surgical services, emergency medical services, ambulance services, dental care services, vision care services, mental health care services, substance abuse services, chiropractic services, podiatric services, laboratory test services and the provision of medical equipment or supplies. “Health care services” does not include pharmaceutical supplies or prescriptions;

(7) “Member” means an individual who pays for the right to receive the benefits of a medical discount plan; and

(8) “Person” has the same meaning as provided in section 38a-1.

(b) No person shall market, advertise or sell to a resident of this state a medical discount plan or any plan material that: (1) Fails to provide to the consumer a clear and conspicuous disclosure that the medical discount plan is not insurance and that the plan only provides for discounted health care services from participating providers within the plan; (2) uses in its marketing materials, advertisements, brochures or member discount cards the term “insurance”, “health plan”, “coverage”, “copay”, “copayments”, “preexisting conditions”, “guaranteed issue”, “premium”, “PPO”, “preferred provider organization” or any other term that could reasonably mislead a person into believing the medical discount plan is insurance, except that such terms may be used as a disclaimer of any relationship between the medical discount plan and insurance; (3) fails to provide the name, address and telephone number of the administrator of the medical discount plan; (4) fails to make available to the consumer through a toll-free telephone number, upon request of the consumer, a complete and accurate list of the participating providers within the plan in the consumer's local area and a list of the services for which the discounts are applicable; (5) fails to make a printed copy of such list available to the consumer upon request commencing with the time the plan is purchased or fails to update the list at least once every six months; (6) fails to use plain language to describe the discounts or access to discounts offered and such failure results in representations of the discounts that are misleading, deceptive or fraudulent; (7) fails to provide the consumer notice of the right to cancel such medical discount plan; (8) offers discounted health care services or products that are not authorized by a contract with each provider listed in conjunction with the medical discount plan; (9) fails to allow a consumer to cancel a medical discount plan not later than thirty days after the date payment is received by the medical discount plan; (10) with respect to a consumer who cancels a medical discount plan pursuant to subdivision (9) of this subsection, fails to guarantee a refund of all membership fees paid to the medical discount plan by the consumer, excluding a reasonable one-time processing fee, not later than thirty days after the member gives timely notification of cancellation of the plan to the medical discount plan organization; or (11) fails to (A) provide at least one member discount card for each member as proof of membership, and (B) prominently display on such member discount card a statement that the medical discount plan is not insurance.

(c) Any person who knowingly operates as a medical discount plan organization in violation of this section shall be fined not more than fifteen thousand dollars. Any person who knowingly aids and abets another that the person knew or reasonably should have known was operating as a medical discount plan organization in violation of this section shall be fined not more than fifteen thousand dollars.

(d) Any person who collects fees for purported membership in a medical discount plan but fails to provide the promised benefits shall be subject to the penalties for larceny under sections 53a-122 to 53a-125b, inclusive, depending on the amount involved. Upon the conviction of such person of larceny, as defined in section 53a-119, if the court does not order financial restitution pursuant to section 53a-28, the commissioner may order reimbursement of any membership fees paid by residents of the state who were harmed by such offense.

(e) Any person licensed in this state as a health insurer, health care center, hospital service corporation, medical service corporation or fraternal benefit society, or any affiliate owned or controlled by such health insurer, health care center, hospital service corporation, medical service corporation or fraternal benefit society, may offer medical discount plans in this state pursuant to such licensure.

(P.A. 05-237, S. 1; P.A. 08-178, S. 51; 08-181, S. 1; P.A. 17-15, S. 47.)

History: P.A. 05-237 effective July 1, 2005; P.A. 08-178 increased maximum fines from $10,000 to $15,000 in Subsec. (c); P.A. 08-181 added Subsec. (a)(3) defining “marketer”, redesignated existing Subsecs. (a)(3) to (a)(7) as new Subsecs. (a)(4) to (a)(8), amended Subsec. (b) by changing “may” to “shall”, and amended Subsec. (d) by authorizing commissioner to order additional penalty of membership fees reimbursement; P.A. 17-15 made a technical change in Subsec. (a)(8).

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(1) Be a corporation, limited liability company, limited liability partnership, or other legal entity organized under the laws of this state or, if a foreign corporation or other foreign entity, authorized to transact business in this state; and

(2) Obtain a license as a medical discount plan organization from the Insurance Commissioner in accordance with this section. The entity shall file an application for a license to operate as a medical discount plan organization with the commissioner on such form as the commissioner prescribes. Such application shall be sworn to by an officer or authorized representative of the applicant, under penalty of false statement, and be accompanied by (A) a copy of the applicant's articles of incorporation, including all amendments; (B) a copy of the applicant's bylaws; (C) a list of the names, addresses, official positions and biographical information of the medical discount plan organization and the individuals who are responsible for conducting the applicant's affairs, including, but not limited to, all members of the board of directors, board of trustees, executive committee, or other governing board or committee, the officers, contracted management company personnel, and any person or entity owning or having the right to acquire ten per cent or more of the voting securities of the applicant, which listing shall fully disclose the extent and nature of any contracts or arrangements between the applicant and any individual who is responsible for conducting the applicant's affairs, including any possible conflicts of interest; (D) for each individual listed in subparagraph (C) of this subdivision as being responsible for conducting the applicant's affairs, a complete biographical statement on forms prescribed by the commissioner; (E) a statement generally describing the applicant, its personnel and the health care services to be offered; (F) a copy of the form of all contracts made or to be made between the applicant and any providers or provider networks regarding the provision of health care services to members; (G) a copy of the form of any contract made or to be made between the applicant and any person listed in subparagraph (C) of this subdivision; (H) a copy of the form of any contract made or to be made between the applicant and any person for the performance on the applicant's behalf of any function, including, but not limited to, marketing, administration, enrollment and subcontracting for the provision of health care services to members; (I) a copy of the applicant's most recent financial statements audited by an independent certified public accountant, or, in the case of an applicant that is a subsidiary of a person or parent corporation that prepares audited financial statements reflecting the consolidated operations of the person or parent corporation, a copy of the person's or parent corporation's most recent financial statements audited by an independent certified public accountant, provided the person or parent corporation also issues a written guarantee that the minimum capital requirements of the applicant required by this section will be met; (J) a description of the proposed method of marketing; (K) a description of the subscriber complaint procedures to be established and maintained; (L) the fee for a medical discount plan organization license set forth in section 38a-11; and (M) a list of the names, addresses and telephone numbers of the marketers the applicant has authorized to market a medical discount plan in this state under a name that is different from the name of the applicant. For purposes of this subdivision, a “contract to be made” shall be determined based on the information known to the applicant on the date the information is filed with the commissioner.

(b) (1) A current and accurate list of authorized marketers, specified in subparagraph (M) of subdivision (2) of subsection (a) of this section, shall be submitted to the commissioner with each renewal fee, as set forth in subsection (c) of this section.

(2) Any change made to the list of authorized marketers, specified in subparagraph (M) of subdivision (2) of subsection (a) of this section, shall be electronically filed with the commissioner. If such change is to add a marketer to a medical discount plan organization's list of authorized marketers, such change shall be electronically filed by such organization prior to the marketer doing business in the state for such organization.

(3) The commissioner may adopt regulations, in accordance with chapter 54, to establish the procedure and format of the electronic filing set forth in this subsection.

(c) If the commissioner finds that the applicant is in compliance with the requirements of this section the commissioner shall issue the applicant a license as a medical discount plan organization which shall expire one year after the date of issue. The commissioner shall renew the license if the commissioner finds that the licensee is in compliance with the requirements of this section and the licensee has paid the renewal fee set forth in section 38a-11.

(d) Prior to applying for a license from the commissioner, a medical discount plan organization shall establish an Internet web site that contains the information described in subsection (s) of this section.

(e) Any license or renewal fee received pursuant to this section shall be deposited in the Insurance Fund established in section 38a-52a.

(f) Nothing in this section shall require a provider who provides discounts to the provider's own patients to obtain or maintain a license as a medical discount plan organization.

(g) Each provider who offers health care services to members under a medical discount plan shall provide such services pursuant to a written agreement. The agreement may be entered into directly by the provider or by a provider network to which the provider belongs.

(h) A provider agreement shall include: (1) A list of the services and products to be provided at a discount; (2) the amount of the discounts or, alternatively, a fee schedule that reflects the provider's discounted rates; and (3) a requirement that the provider will not charge members more than the discounted rates.

(i) A provider agreement between a medical discount plan organization and a provider network shall require that the provider network have written agreements with its providers that: (1) Contain the terms set forth in subsection (h) of this section; (2) authorize the provider network to contract with the medical discount plan organization on behalf of the provider; and (3) require the network to maintain an up-to-date list of its contracted providers and to provide that list on a quarterly basis to the medical discount plan organization. No medical discount plan organization may enter into or renew a contractual relationship with a provider network that is not licensed in accordance with section 38a-479aa.

(j) The medical discount plan organization shall maintain a copy of each active agreement that it has entered into with a provider or provider network.

(k) Each medical discount plan organization shall at all times (1) maintain a net worth of at least two hundred fifty thousand dollars, or (2) post a surety bond in the amount of one hundred thousand dollars.

(l) The commissioner shall not issue or renew a license under this section unless the medical discount plan organization has (1) a net worth of at least two hundred fifty thousand dollars, or (2) posted a surety bond in the amount of one hundred thousand dollars.

(m) The commissioner may suspend the authority of a medical discount plan organization to enroll new members, revoke any license issued to a medical discount plan organization, refuse to renew a license of a medical discount plan organization or order compliance if the commissioner finds that any of the following conditions exist:

(1) The organization is not operating in compliance with this section or section 38a-479qq;

(2) The organization does not have the minimum net worth required by this section;

(3) The organization has advertised, sold or attempted to sell its services in such a manner as to misrepresent its services or capacity for service or has engaged in deceptive, misleading or unfair practices with respect to advertising or sales;

(4) The organization is not fulfilling its obligations as a medical discount plan organization; or

(5) The continued operation of the medical discount plan organization would be hazardous to its members.

(n) If the commissioner has reasonable cause to believe that grounds for the suspension, nonrenewal or revocation of a license exist, the commissioner shall notify the medical discount plan organization in writing specifically stating the grounds for suspension, nonrenewal or revocation.

(o) When the license of a medical discount plan organization is surrendered, nonrenewed or revoked, the organization shall, immediately following the effective date of the order, wind up and settle the affairs transacted under the license. The organization shall not engage in any further marketing, advertising, sales, collection of fees or renewal of contracts as a medical discount plan organization, and its authorized marketers shall not engage in any further marketing, advertising or sales on behalf of such medical discount plan organization.

(p) The commissioner shall, in any order suspending the authority of a medical discount plan organization to enroll new members, specify the period during which the suspension is to be in effect and the conditions, if any, that shall be met by the medical discount plan organization prior to reinstatement of its license to enroll new members. The commissioner may rescind or modify the order of suspension prior to the expiration of the suspension period.

(q) The commissioner shall not reinstate a license: (1) Unless reinstatement is requested by the medical discount plan organization, and (2) if the commissioner finds that the circumstances which led to the suspension still exist or are likely to recur.

(r) Each medical discount plan organization shall provide the commissioner at least thirty days' advance written notice of any change in the medical discount plan organization's name, address, principal business address or mailing address.

(s) Each medical discount plan organization shall maintain an up-to-date list of the names and addresses of the providers with which it has contracted on an Internet web site, the address of which shall be prominently displayed on all its marketing materials, advertisements, brochures and member discount cards. The list shall include providers with whom the medical discount plan organization has contracted directly as well as providers who will provide services to the organization's members as part of a provider network with which the medical discount plan organization has contracted.

(t) Each medical discount plan organization shall (1) prominently display on any member discount card the names or identifying logos or trademarks of any provider networks with whom the medical discount plan organization has a contract, and (2) provide the names of such provider networks to members upon request.

(u) No marketer shall market, advertise or sell to a resident of this state a medical discount plan under a name that is different than the medical discount plan organization's name unless: (1) The medical discount plan organization has obtained a license from the Insurance Commissioner in accordance with this section; (2) the marketer is listed on such medical discount plan organization's list of authorized marketers as set forth in subparagraph (M) of subdivision (2) of subsection (a) or subsection (b) of this section; (3) the name, address and telephone number of the medical discount plan organization appears on the plan materials; and (4) the marketer does not contract directly with providers or provider networks. A marketer shall not be required to obtain a license from the commissioner.

(v) (1) A medical discount plan organization may market directly or contract with marketers for the distribution of a medical discount plan. The medical discount plan organization shall execute a written agreement with a marketer and comply with the requirements set forth in subparagraph (M) of subdivision (2) of subsection (a) or subsection (b) of this section, as applicable, prior to the marketing, advertising or selling of such medical discount plan by such marketer. Such written agreement shall prohibit the marketer from using any advertising and marketing materials, including, but not limited to, brochures and medical discount plan cards, without the written approval of the medical discount plan organization prior to the usage of such advertising and marketing materials.

(2) If a marketer uses any marketing or advertising materials that are in violation of subsection (b) of section 38a-479qq, the commissioner may order a medical discount plan organization to immediately remove such marketer from such medical discount plan organization's list of authorized marketers specified in subparagraph (M) of subdivision (2) of subsection (a) of this section. In addition, the commissioner may order the medical discount plan organization to return membership fees paid by residents of the state who were harmed by such violation.

(3) During an investigation by the commissioner of an alleged violation set forth in subdivision (2) of this subsection, a medical discount plan organization shall make available to the commissioner, upon request, a copy of such organization's contract with such marketer, and any marketing and advertising materials of such marketer.

(w) Each medical discount plan organization that contracts with a marketer shall be bound by and responsible for the activities of such marketer, within the scope of the marketer's agency relationship, and shall cooperate in any investigation of the activities of such contracted marketer as ordered by the commissioner.

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

(y) Any person who violates any provision of this section shall be fined not more than three thousand dollars.

(P.A. 05-237, S. 2; P.A. 08-178, S. 52; 08-181, S. 2; P.A. 10-5, S. 17; P.A. 14-235, S. 25.)

History: P.A. 05-237 effective January 1, 2006; P.A. 08-178 increased maximum fine from $2,000 to $3,000 in Subsec. (u); P.A. 08-181 made technical changes, amended Subsec. (a)(2) by adding Subpara. (M) re list of authorized marketers, added new Subsec. (b) re submission of list of authorized marketers, redesignated existing Subsecs. (b) to (s) as new Subsecs. (c) to (t) and made conforming changes, amended new Subsec. (o) by prohibiting authorized marketers from engaging in further marketing, advertising or sales on behalf of a medical discount plan organization whose license has been surrendered, nonrenewed or revoked, inserted new Subsec. (u) re prerequisites for marketers, new Subsec. (v) re required written agreement and access to materials by commissioner during an investigation and new Subsec. (w) re liability of medical discount plan organization for activities of its marketers and requirement to cooperate in an investigation, and redesignated existing Subsecs. (t) and (u) as Subsecs. (x) and (y); P.A. 10-5 amended Subsec. (b)(3) by deleting “and acknowledgement”, effective May 5, 2010; P.A. 14-235 made a technical change in Subsec. (p).

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Secs. 38a-479ss to 38a-479zz. Reserved for future use.

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PART Id

HEALTH INSURANCE: PHARMACY BENEFITS MANAGERS

Sec. 38a-479aaa. Pharmacy benefits managers. Definitions. As used in this section and sections 38a-479bbb to 38a-479iii, inclusive:

(1) “Commissioner” means the Insurance Commissioner;

(2) “Department” means the Insurance Department;

(3) “Drug” has the same meaning as provided in section 21a-92;

(4) “Person” has the same meaning as provided in section 38a-1;

(5) “Pharmacist services” includes (A) drug therapy and other patient care services provided by a licensed pharmacist intended to achieve outcomes related to the cure or prevention of a disease, elimination or reduction of a patient's symptoms, and (B) education or intervention by a licensed pharmacist intended to arrest or slow a disease process;

(6) “Pharmacist” means an individual licensed to practice pharmacy under section 20-590, 20-591, 20-592 or 20-593, and who is thereby recognized as a health care provider by the state of Connecticut;

(7) “Pharmacy” means a place of business where drugs may be sold at retail and for which a pharmacy license has been issued to an applicant pursuant to section 20-594; and

(8) “Pharmacy benefits manager” or “manager” means any person that administers the prescription drug, prescription device, pharmacist services or prescription drug and device and pharmacist services portion of a health benefit plan on behalf of plan sponsors such as self-insured employers, insurance companies, labor unions and health care centers.

(P.A. 07-200, S. 1; P.A. 14-193, S. 2; P.A. 18-68, S. 9.)

History: P.A. 07-200 effective January 1, 2008; P.A. 14-193 added reference to Sec. 38a-479iii in introductory language; P.A. 18-68 made technical changes in Subdivs. (3) and (4).

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Sec. 38a-479bbb. Registration of pharmacy benefits managers required. Application for registration. Fee. Surety bond. Exemption from registration. (a) Except as provided in subsection (d) of this section, no person shall act as a pharmacy benefits manager in this state without first obtaining a certificate of registration from the commissioner.

(b) Any person seeking a certificate of registration shall apply to the commissioner, in writing, on a form provided by the commissioner. The application form shall state (1) the name, address, official position and professional qualifications of each individual responsible for the conduct of the affairs of the pharmacy benefits manager, including all members of the board of directors, board of trustees, executive committee, other governing board or committee, the principal officers in the case of a corporation, the partners or members in the case of a partnership or association and any other person who exercises control or influence over the affairs of the pharmacy benefits manager, and (2) the name and address of the applicant's agent for service of process in this state.

(c) Each application for a certificate of registration shall be accompanied by (1) a nonrefundable fee of fifty dollars, and (2) evidence of a surety bond in an amount equivalent to ten per cent of one month of claims in this state over a twelve-month average, except that such bond shall not be less than twenty-five thousand dollars or more than one million dollars.

(d) Any pharmacy benefits manager operating as a line of business or affiliate of a health insurer, health care center, hospital service corporation, medical service corporation or fraternal benefit society licensed in this state or any affiliate of such health insurer, health care center, hospital service corporation, medical service corporation or fraternal benefit society shall not be required to obtain a certificate of registration. Such health insurer, health care center, hospital service corporation, medical service corporation or fraternal benefit society shall notify the commissioner annually, in writing, on a form provided by the commissioner, that it is affiliated with or operating a business as a pharmacy benefits manager.

(P.A. 07-200, S. 2; P.A. 14-193, S. 3; 14-235, S. 54.)

History: P.A. 07-200 effective January 1, 2008; P.A. 14-193 deleted former Subsec. (e) re 2008 registration requirement for pharmacy benefits manager; P.A. 14-235 made identical change as P.A. 14-193.

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Sec. 38a-479ccc. Certificate of registration; when issued or refused. Suspension, revocation or refusal to issue or renew registration; grounds. (a) Upon receipt of a completed application, evidence of a surety bond and fee, the commissioner shall: (1) Issue and deliver to the applicant a certificate of registration; or (2) refuse to issue the certificate.

(b) The commissioner may suspend, revoke or refuse to issue or renew any certificate of registration for: (1) Conduct of a character likely to mislead, deceive or defraud the public or the commissioner; (2) unfair or deceptive business practices; or (3) nonpayment of the renewal fee.

(c) The commissioner shall not suspend or revoke any certificate of registration except upon notice and hearing in accordance with chapter 54.

(P.A. 07-200, S. 3.)

History: P.A. 07-200 effective January 1, 2008.

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Sec. 38a-479ddd. Hearing on denial of certificate. Subsequent application. (a) Upon refusal to issue or renew a certificate, the commissioner shall notify the applicant of the denial and of the applicant's right to request a hearing within ten days from the date of receipt of the notice of denial.

(b) If the applicant requests a hearing within such ten days, the commissioner shall give notice of the grounds for the commissioner's refusal and shall conduct a hearing concerning such refusal in accordance with the provisions of chapter 54 concerning contested cases.

(c) If the commissioner's denial of a certificate is sustained after such hearing, an applicant may make a new application not less than one year after the date on which such denial was sustained.

(P.A. 07-200, S. 4.)

History: P.A. 07-200 effective January 1, 2008.

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Sec. 38a-479eee. Claims payment to be made by electronic funds transfer upon written request. Upon written request from a pharmacy, a pharmacy benefits manager shall pay claims to such pharmacy by electronic funds transfer. Any such payments shall be made within the time periods specified under subparagraph (B) of subdivision (15) of section 38a-816.

(P.A. 07-200, S. 5; P.A. 14-193, S. 4.)

History: P.A. 07-200 effective January 1, 2008; P.A. 14-193 replaced former provisions re investigations and hearings with provisions re electronic funds transfer payments.

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Sec. 38a-479fff. Expiration of certificates of registration. Renewal. Fees. (a) All certificates of registration issued under section 38a-479ccc shall expire annually on December thirty-first.

(b) Any person seeking to renew a certificate of registration shall apply to the commissioner, in writing, on a form provided by the commissioner. The application for renewal shall be in such form as the commissioner prescribes. Such application shall be accompanied by a nonrefundable fee of fifty dollars. Any late payment of such fee shall include a penalty fee of fifty dollars.

(P.A. 07-200, S. 6.)

History: P.A. 07-200 effective January 1, 2008.

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Sec. 38a-479ggg. Regulations. The commissioner shall adopt regulations, in accordance with chapter 54, to implement the provisions of sections 38a-479aaa to 38a-479hhh, inclusive. Such regulations shall specify the contents of the application form and any other form or report required under the provisions of said sections.

(P.A. 07-200, S. 7.)

History: P.A. 07-200 effective January 1, 2008.

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Sec. 38a-479hhh. Investigations and hearings. Powers of commissioner. Appeals. (a) The commissioner may conduct investigations and hold hearings on any matter under the provisions of sections 38a-479aaa to 38a-479iii, inclusive. The commissioner may issue subpoenas, administer oaths, compel testimony and order the production of books, records and documents. If any person refuses to appear, to testify or to produce any book, record, paper or document when so ordered, upon application of the commissioner, a judge of the Superior Court may make such order as may be appropriate to aid in the enforcement of this section.

(b) Any person aggrieved by an order or decision of the commissioner under sections 38a-479aaa to 38a-479iii, inclusive, may appeal therefrom in accordance with the provisions of section 4-183.

(P.A. 07-200, S. 8; P.A. 14-193, S. 5.)

History: P.A. 07-200 effective January 1, 2008; P.A. 14-193 added Subsec. (a) re investigations and hearings, designated existing provision re person aggrieved by order or decision as Subsec. (b) and amended same by adding reference to Sec. 38a-479iii.

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Sec. 38a-479iii. Pharmacy audits. (a) As used in this section:

(1) “Extrapolation” means the practice of inferring a frequency of dollar amount of overpayments, underpayments, nonvalid claims or other errors on any portion of claims submitted, based on the frequency or dollar amount of overpayments, underpayments, nonvalid claims or other errors actually measured in a sample of claims;

(2) “Pharmacy audit” means an audit, conducted on-site or remotely by or on behalf of a pharmacy benefits manager or plan sponsor of any records of a pharmacy for prescription drugs or prescription devices dispensed by such pharmacy to beneficiaries of a health benefit plan. “Pharmacy audit” does not include (A) a concurrent review or desk audit that occurs within three business days of the pharmacy's transmission of a claim to a pharmacy benefits manager or plan sponsor, or (B) a concurrent review or desk audit where no charge-back or recoupment is demanded by the pharmacy benefits manager or plan sponsor;

(3) “Plan sponsor” has the same meaning as described in section 38a-479aaa.

(b) (1) No entity other than a pharmacy benefits manager or a plan sponsor shall conduct a pharmacy audit unless such entity and manager or sponsor, as applicable, have executed a written agreement for the conducting of pharmacy audits. Prior to conducting a pharmacy audit on behalf of such manager or sponsor, such entity shall notify the pharmacy in writing that such entity and manager or sponsor, as applicable, have executed such agreement.

(2) Except as otherwise provided by state or federal law, an entity conducting a pharmacy audit may have access to a pharmacy's previous pharmacy audit report only if such report was prepared by such entity.

(3) Any information collected during a pharmacy audit shall be confidential by law, except that the entity conducting the pharmacy audit may share such information with the pharmacy benefits manager and the plan sponsor, for which such pharmacy audit is being conducted.

(4) No entity conducting a pharmacy audit shall compensate, directly or indirectly, any of its employees or any contractor such entity contracts with to conduct a pharmacy audit, based on the amount claimed or the actual amount recouped from the pharmacy being audited.

(A) Provide the pharmacy being audited at least ten business days' prior written notice before conducting a pharmacy audit;

(B) Provide the pharmacy being audited with a masked list of prescriptions to assist the pharmacy to prepare for the pharmacy audit. A list is considered masked if the last two numbers of a prescription are marked with an “X”;

(C) Not initiate or schedule a pharmacy audit during the first five business days of any month for any pharmacy that averages in excess of six hundred prescriptions filled per week, without the express consent of the pharmacy;

(D) Make all determinations regarding the validity of a prescription or other record consistent with sections 20-612 to 20-623, inclusive, or as specified in federal risk management programs;

(E) Accept paper or electronic signature logs that document the delivery of prescription drug and device and pharmacist services to a health plan beneficiary or such beneficiary's agent; and

(F) Provide to the representative of the pharmacy, prior to leaving the pharmacy at the conclusion of an on-site portion of a pharmacy audit, a complete list of records reviewed.

(2) Any pharmacy audit that involves clinical judgment shall be conducted by or in consultation with a licensed pharmacist.

(3) No pharmacy audit shall cover (A) a period of more than twenty-four months after the date a claim was submitted by the pharmacy to the pharmacy benefits manager or plan sponsor unless a longer period is required by law, or (B) more than two hundred fifty prescriptions.

(d) (1) (A) Not later than sixty calendar days after an entity concludes a pharmacy audit and before such entity issues a final pharmacy audit report, such entity shall provide an initial pharmacy audit review to the pharmacy. The pharmacy may, within thirty calendar days after it receives such initial review, respond to the findings in such initial review.

(B) To validate the pharmacy record and delivery, a pharmacy may use authentic and verifiable statements or records, including, but not limited to, medication administration records of a nursing home, assisted living facility, hospital or health care provider with prescriptive authority.

(C) To validate claims in connection with prescriptions or changes in prescriptions, or refills of prescription drugs, a pharmacy may use any valid prescription, including, but not limited to, medication administration records, facsimiles, electronic prescriptions, electronically stored images of prescriptions, electronically created annotations or documented telephone calls from the prescribing health care provider or such provider's agent. Documentation of an oral prescription order that has been verified by the prescribing health care provider shall meet the provisions of this subparagraph for the initial audit review.

(D) No entity conducting a pharmacy audit may use extrapolation to calculate penalties or amounts to be charged back or recouped unless otherwise required by federal requirements or federal plans. No such entity shall include dispensing fees in the calculation of overpayments unless a prescription is considered a misfill. As used in this subparagraph, “misfill” means a prescription that was not dispensed, a prescription error, a prescription whereby the prescriber denied the authorization request or where an extra dispensing fee was charged.

(2) (A) Not later than sixty calendar days after any responses from the pharmacy under subdivision (1) of this subsection are received by the entity conducting the pharmacy audit or, if no such responses are received, after the entity concludes a pharmacy audit, such entity shall issue a final pharmacy audit report that takes into consideration any responses provided to such entity by the pharmacy.

(B) A pharmacy may appeal a final pharmacy audit report in accordance with the procedures established by the entity conducting the pharmacy audit.

(e) (1) No pharmacy shall be subject to charge-back or recoupment for a clerical or recordkeeping error in a required document or record, including a typographical error, scrivener's error or computer error, unless such error resulted in actual financial harm to the pharmacy benefits manager, plan sponsor or a plan beneficiary.

(2) No entity conducting a pharmacy audit or person acting on behalf of such entity shall charge-back or recoup, attempt to charge-back or recoup, or assess or collect penalties from a pharmacy until the time period to file an appeal of a final pharmacy audit report has passed or the appeals process has been exhausted, whichever is later. If an identified discrepancy in a pharmacy audit exceeds twenty-five thousand dollars, future payments to the pharmacy in excess of such amount may be withheld pending adjudication of an appeal. No interest shall accrue for any party during the audit period, beginning with the notice of the pharmacy audit and ending with the conclusion of the appeals process.

(f) The provisions of this section shall not apply to an audit of pharmacy records conducted when (1) fraud or other intentional or wilful misrepresentation is indicated by physical review or review of claims data or statements, or (2) other investigative methods indicate a pharmacy is or has been engaged in criminal wrongdoing, fraud or other intentional or wilful misrepresentation.

(P.A. 14-193, S. 1.)

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Secs. 38a-479jjj to 38a-479nnn. Reserved for future use.

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PART Ie

HEALTH INSURANCE: PRESCRIPTION DRUG COSTS

Sec. 38a-479ooo. Definitions. For the purposes of this part:

(1) “Commissioner” means the Insurance Commissioner.

(2) “Department” means the Insurance Department.

(3) “Drug” has the same meaning as provided in section 21a-92.

(4) “Health care plan” means an individual or a group health insurance policy that provides coverage of the types specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 and includes coverage for outpatient prescription drugs.

(6) “Person” has the same meaning as provided in section 38a-1.

(7) “Pharmacist” has the same meaning as provided in section 38a-479aaa.

(8) “Pharmacist services” has the same meaning as provided in section 38a-479aaa.

(9) “Pharmacy” has the same meaning as provided in section 38a-479aaa.

(10) “Pharmacy benefits manager” or “manager” means any person that administers the prescription drug, prescription device, pharmacist services or prescription drug and device and pharmacist services portion of a health care plan on behalf of a health carrier.

(11) (A) “Rebate” means a discount or concession, which affects the price of an outpatient prescription drug, that a pharmaceutical manufacturer directly provides to a (i) health carrier for an outpatient prescription drug manufactured by the pharmaceutical manufacturer, or (ii) pharmacy benefits manager after the manager processes a claim from a pharmacy or a pharmacist for an outpatient prescription drug manufactured by the pharmaceutical manufacturer.

(B) “Rebate” does not mean a bona fide service fee, as such term is defined in Section 447.502 of Title 42 of the Code of Federal Regulations, as amended from time to time.

(12) “Specialty drug” means a prescription outpatient specialty drug covered under the Medicare Part D program established pursuant to Public Law 108-173, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, as amended from time to time, that exceeds the specialty tier cost threshold established by the Centers for Medicare and Medicaid Services.

(P.A. 18-41, S. 1.)

History: P.A. 18-41 effective January 1, 2020.

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Sec. 38a-479ppp. Annual report by pharmacy benefits managers. Standardized form. Confidentiality of information. Penalty. Regulations. Commissioner's report to the General Assembly. (a) Not later than March 1, 2021, and annually thereafter, each pharmacy benefits manager shall file a report with the commissioner for the immediately preceding calendar year. The report shall contain the following information for health carriers that delivered, issued for delivery, renewed, amended or continued health care plans that included a pharmacy benefit managed by the pharmacy benefits manager during such calendar year:

(1) The aggregate dollar amount of all rebates concerning drug formularies used by such health carriers that such manager collected from pharmaceutical manufacturers that manufactured outpatient prescription drugs that (A) were covered by such health carriers during such calendar year, and (B) are attributable to patient utilization of such drugs during such calendar year; and

(2) The aggregate dollar amount of all rebates, excluding any portion of the rebates received by such health carriers, concerning drug formularies that such manager collected from pharmaceutical manufacturers that manufactured outpatient prescription drugs that (A) were covered by such health carriers during such calendar year, and (B) are attributable to patient utilization of such drugs by covered persons under such health care plans during such calendar year.

(b) The commissioner shall establish a standardized form for reporting information pursuant to subsection (a) of this section after consultation with pharmacy benefits managers. The form shall be designed to minimize the administrative burden and cost of reporting on the department and pharmacy benefits managers.

(c) All information submitted to the commissioner pursuant to subsection (a) of this section shall be exempt from disclosure under the Freedom of Information Act, as defined in section 1-200, except to the extent such information is included on an aggregated basis in the report required by subsection (d) of this section. The commissioner shall not disclose information submitted pursuant to subdivision (1) of subsection (a) of this section, or information submitted pursuant to subdivision (2) of said subsection in a manner that (1) is likely to compromise the financial, competitive or proprietary nature of such information, or (2) would enable a third party to identify a health care plan, health carrier, pharmacy benefits manager, pharmaceutical manufacturer, or the value of a rebate provided for a particular outpatient prescription drug or therapeutic class of outpatient prescription drugs.

(d) Not later than March 1, 2022, and annually thereafter, the commissioner shall submit a report, in accordance with section 11-4a, to the joint standing committee of the General Assembly having cognizance of matters relating to insurance. The report shall contain (1) an aggregation of the information submitted to the commissioner pursuant to subsection (a) of this section for the immediately preceding calendar year, and (2) such other information as the commissioner, in the commissioner's discretion, deems relevant for the purposes of this section. Not later than February 1, 2022, and annually thereafter, the commissioner shall provide each pharmacy benefits manager and any third party affected by submission of a report required by this subsection with a written notice describing the content of the report.

(e) The commissioner may impose a penalty of not more than seven thousand five hundred dollars on a pharmacy benefits manager for each violation of this section.

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

(P.A. 18-41, S. 2.)

History: P.A. 18-41 effective January 1, 2020.

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Sec. 38a-479qqq. Annual report by health carriers. Regulations. (a) Each health carrier that delivers, issues for delivery, renews, amends or continues a health care plan on or after January 1, 2021, shall submit the following information and data to the commissioner, for such health care plan for the immediately preceding calendar year, at the time that such health carrier submits a rate filing for such health care plan pursuant to sections 38a-183, 38a-481, or 38a-513, as applicable:

(1) For covered outpatient prescription drugs that were prescribed to insureds under such health care plan during such calendar year, the names of:

(A) The twenty-five most frequently prescribed outpatient prescription drugs;

(B) The twenty-five outpatient prescription drugs that the health care plan covered at the greatest cost, calculated by using the total annual plan spending by such health care plan for each outpatient prescription drug; and

(C) The twenty-five outpatient prescription drugs that experienced the greatest year-over-year increase in cost, calculated by using the total annual plan spending by such health care plan for each outpatient prescription drug.

(2) The portion of the premium for such health care plan that is attributable to each of the following categories of covered outpatient prescription drugs that were prescribed to insureds under such health care plan during such calendar year:

(A) Brand name drugs;

(B) Generic drugs; and

(3) The year-over-year increase, calculated on a per member, per month basis and expressed as a percentage, in the total annual cost of each category of covered outpatient prescription drugs set forth in subdivision (2) of this subsection.

(4) A comparison, calculated on a per member, per month basis, of the year-over-year increase in the cost of covered outpatient prescription drugs to the year-over-year increase in the costs of other contributors to the premium cost of such health care plan.

(5) The name of each specialty drug covered during such calendar year.

(6) The names of the twenty-five most frequently prescribed outpatient prescription drugs for which the health carrier received rebates from pharmaceutical manufacturers during such calendar year.

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

(P.A. 18-41, S. 3.)

History: P.A. 18-41 effective January 1, 2020.

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Sec. 38a-479rrr. Annual certification by health carriers. Beginning on March 1, 2022, and annually thereafter, each health carrier shall submit to the commissioner, in a form and manner prescribed by the commissioner, a written certification for the immediately preceding calendar year, certifying that the health carrier accounted for all rebates in calculating the premium for health care plans that such health carrier delivered, issued for delivery, renewed, amended or continued during such calendar year.

(P.A. 18-41, S. 4.)

History: P.A. 18-41 effective January 1, 2020.

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Sec. 38a-479sss. Annual report by commissioner to the General Assembly re outpatient prescription drug costs. Not later than March 1, 2022, and annually thereafter, the commissioner shall submit a report, in accordance with section 11-4a, to the joint standing committee of the General Assembly having cognizance of matters relating to insurance. The report shall contain (1) an aggregation of the information and data submitted to the commissioner pursuant to section 38a-479qqq for the immediately preceding calendar year, (2) a description of the impact of the cost of outpatient prescription drugs on health insurance premiums in this state, and (3) such other information as the commissioner, in the commissioner's discretion, deems relevant to the cost of outpatient prescription drugs in this state.

(P.A. 18-41, S. 5.)

History: P.A. 18-41 effective January 1, 2020.

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Sec. 38a-479ttt. Annual report by commissioner to the General Assembly re prescription drug rebates. Not later than March 1, 2021, and annually thereafter, the commissioner shall prepare a report, for the immediately preceding calendar year, describing the rebate practices of health carriers. The report shall contain (1) an explanation of the manner in which health carriers accounted for rebates in calculating premiums for health care plans delivered, issued for delivery, renewed, amended or continued during such year, (2) a statement disclosing whether, and describing the manner in which, health carriers made rebates available to insureds at the point of purchase during such year, (3) any other manner in which health carriers applied rebates during such year, and (4) such other information as the commissioner, in the commissioner's discretion, deems relevant for the purposes of this section. The commissioner shall publish a copy of the report on the department's Internet web site.

(P.A. 18-41, S. 6.)

History: P.A. 18-41 effective January 1, 2020.

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PART II

INDIVIDUAL HEALTH INSURANCE

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

(b) Except as otherwise provided in this title, the provisions of sections 38a-481 to 38a-488, inclusive, 38a-492, 38a-502 and 38a-505 shall not apply to any subscriber contract issued by a health care center.

(1949 Rev., S. 6188; 1951, 1953, S. 2842d; 1957, P.A. 448, S. 46; 1967, P.A. 326; P.A. 79-376, S. 59; P.A. 88-326, S. 5; P.A. 90-243, S. 71; P.A. 15-118, S. 67; 15-247, S. 36.)

History: 1967 act added proviso in Subdiv. (2) re furnishing of information which insurer would be required to certify to plan administrator under federal Welfare and Pension Plans Disclosure Act; P.A. 79-376 added reference to Secs. 38-166 to 38-172 and substituted “workers' compensation” for “workmen's compensation”; P.A. 88-326 required the commissioner to adopt regulations establishing a procedure for review of group health and accident policies, life insurance policies and annuity contracts, and added a new Subsec. (b) concerning the commissioner's disapproval of any policy form; P.A. 90-243 substituted reference to “group health insurance policy” for reference to accident and health policies, deleted former provisions re commissioner's approval of forms and re group policies and added a new Subsec. (b) exempting health care centers from certain statutory provisions; Sec. 38-174 transferred to Sec. 38a-480 in 1991; P.A. 15-118 amended Subsec. (b) to add “Except as otherwise provided in this title,” and make technical change; P.A. 15-247 made identical changes as P.A. 15-118, effective July 10, 2015.

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Sec. 38a-481. (Formerly Sec. 38-165). Filing of policy form, application, classification of risks and rates. Approval of rates. Prescription drug rebates. Medicare supplement policies: Age, gender, previous claim or medical history rating prohibited. Reduction of payments on basis of Medicare eligibility. Optional life insurance rider. Treatment of health insurance issued to association or certain other insurance arrangements. Special enrollment periods. Grandfathered and nongrandfathered plans. (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. Rate filings shall include the information and data required under section 38a-479qqq if the policy is subject to said section, and an actuarial memorandum that includes, but is not limited to, pricing assumptions and claims experience, and premium rates and loss ratios from the inception of the policy. Each premium rate filed on or after January 1, 2021, shall, if the insurer intends to account for rebates, as defined in section 38a-479ooo in the manner specified in section 38a-479rrr, account for such rebates in such manner, if the policy is subject to section 38a-479rrr. The commissioner may adopt regulations, in accordance with the provisions of 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 that are unfair or deceptive or that encourage misrepresentation of the policy. The commissioner shall notify, in writing, the insurer that 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. As used in this subsection, “loss ratio” means the ratio of incurred claims to earned premiums by the number of years of policy duration for all combined durations.

(b) No rate filed under the provisions of subsection (a) of this section shall be effective until it has been approved by the commissioner in accordance with regulations adopted pursuant to this subsection. The commissioner shall adopt regulations, in accordance with the provisions of chapter 54, to prescribe standards to ensure that such rates shall not be excessive, inadequate or unfairly discriminatory. The commissioner may disapprove such rate 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 that 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.

(d) No individual health insurance policy delivered, issued for delivery, renewed, amended or continued in this state shall include any provision that reduces payments on the basis that an individual is eligible for Medicare by reason of age, disability or end-stage renal disease, unless such individual enrolls in Medicare. If such individual enrolls in Medicare, any such reduction shall be only to the extent such coverage is provided by Medicare.

(e) Nothing in this chapter shall preclude the issuance of an individual health insurance policy that includes an optional life insurance rider, provided the optional life insurance rider shall 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.

(f) Health insurance issued to an association or other insurance arrangement that is not made up solely of employer groups shall be treated as individual health insurance.

(g) (1) As used in this subsection, “Affordable Care Act” means the Patient Protection and Affordable Care Act, P.L. 111-148, as amended from time to time, and regulations adopted thereunder, and “grandfathered plan” has the same meaning as “grandfathered health plan” as provided in the Affordable Care Act.

(2) Each individual health insurance policy subject to the Affordable Care Act shall (A) be offered on a guaranteed issue basis with respect to all eligible individuals or dependents, and (B) provide special enrollment periods to (i) all eligible individuals or dependents as set forth in 45 CFR 147.104, as amended from time to time, and (ii) all eligible pregnant individuals not more than thirty days after the commencement of the pregnancy, as certified by any licensed health care provider acting within the scope of such health care provider's practice. Coverage under subparagraph (B)(ii) of this subdivision shall be (I) effective on the first of the month in which the individual receives such certification, and (II) limited to eligible individuals who do not have, at a minimum, essential benefits as determined under the Affordable Care Act or the coverage requirements under chapter 700c. Nothing in this subdivision shall be construed to prohibit any person from enrolling in an individual health insurance policy offered or sold through the exchange or not offered or sold through the exchange.

(3) With respect to grandfathered plans of a policy under subdivision (2) of this subsection, the premium rates charged or offered shall be established on the basis of a single pool of all grandfathered plans.

(4) With respect to nongrandfathered plans of a policy under subdivision (2) of this subsection:

(A) The premium rates charged or offered shall be established on the basis of a single pool of all nongrandfathered plans, adjusted to reflect one or more of the following classifications:

(i) Age, in accordance with a uniform age rating curve established by the commissioner;

(ii) Geographic area, as defined by the commissioner;

(iii) Tobacco use, except that such rate may not vary by a ratio of greater than 1.5 to 1.0 and may only be applied with respect to individuals who may legally use tobacco under state and federal law. For purposes of this subparagraph, “tobacco use” means the use of tobacco products four or more times per week on average within a period not longer than the six months immediately preceding. “Tobacco use” does not include the religious or ceremonial use of tobacco;

(B) Total premium rates for family coverage shall be determined by adding the premiums for each individual family member, except that with respect to family members under twenty-one years of age, the premiums for only the three oldest covered children shall be taken into account in determining the total premium rate for such family.

(5) Premium rates for a grandfathered or nongrandfathered policy under subdivision (2) of this subsection may vary by (A) actuarially justified differences in plan design, and (B) actuarially justified amounts to reflect the policy's provider network and administrative expense differences that can be reasonably allocated to such policy.

(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; P.A. 10-5, S. 18; P.A. 11-19, S. 29; P.A. 12-145, S. 11; P.A. 13-149, S. 1; P.A. 14-235, S. 55; P.A. 15-118, S. 50; 15-247, S. 6; P.A. 18-41, S. 8; 18-43, S. 2.)

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; P.A. 10-5 made a technical change in Subsec. (b), effective May 5, 2010; P.A. 11-19 amended Subsec. (c) to delete provisions re Medicare supplement plans “H” to “J”; P.A. 12-145 made a technical change in Subsec. (d), effective June 15, 2012; P.A. 13-149 amended Subsec. (a) by adding provision requiring for rate filings an actuarial memorandum that includes pricing assumptions and claims experience, premium rates and loss ratios from inception of the policy, amended Subsec. (b) by deleting provision re 30-day period after which policy is deemed approved, deleted former Subsecs. (d) and (e) re loss ratio guarantee, redesignated existing Subsecs. (f), (g) and (h) as Subsecs. (d), (e) and (f), and made technical changes in redesignated Subsec. (e), effective June 21, 2013; P.A. 14-235 amended Subsec. (d) to delete former Subdiv. (2) re definition of “experience period” and make conforming changes; P.A. 15-118 made technical changes in Subsecs. (a) to (c); P.A. 15-247 amended Subsec. (a) by adding definition of “loss ratio”, amended Subsec. (b) by deleting provision re 30-day period for disapproval of rate, amended Subsec. (d) by deleting definition of “loss ratio” and adding provision re reduction of payments on basis of Medicare eligibility, deleted former Subsec. (f) re prohibited underwriting practices, added new Subsec. (f) re treatment of health insurance issued to association or other insurance arrangement as individual health insurance, added Subsec. (g) re requirements for individual policies subject to Affordable Care Act and grandfathered and nongrandfathered plans, and made technical and conforming changes, effective July 10, 2015; P.A. 18-41 amended Subsec. (a) by adding provisions re inclusion of information and data required under Sec. 38a-479qqq and accounting for rebates in manner specified in Sec. 38a-479rrr and replacing “shall” with “may” re commissioner's authority to adopt regulations, effective January 1, 2020; P.A. 18-43 amended Subsec. (g)(2) by designating existing provision re policies subject to Affordable Care Act be offered on guaranteed issue basis with respect to all eligible individuals or dependents as Subpara. (A), adding Subpara. (B) re special enrollment periods, and adding provisions re coverage under Subpara. (B) and enrollment in individual health insurance policy, effective January 1, 2019.

See Sec. 38a-477a re notification by Insurance Commissioner of required benefits and policy forms.

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

Annotation to former section 38-165:

Cited. 186 C. 507.

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Sec. 38a-482. (Formerly Sec. 38-166). Form of policy. No individual health insurance policy shall be delivered or issued for delivery to any person in this state unless: (1) The entire money and other considerations therefor are expressed therein; (2) the time at which the insurance takes effect and terminates is expressed therein; (3) such policy purports to insure only one person, except that a policy may insure, originally or by subsequent amendment, upon the application of an adult member of a family, who shall be deemed the policyholder, any two or more eligible members of such family, including spouse, dependent children or any children as specified in section 38a-497, and any other person dependent upon the policyholder; (4) the style, arrangement and overall appearance of the policy give no undue prominence to any portion of the text, and every printed portion of the text of the policy and of any endorsements or attached papers is plainly printed in light-faced type of a style in general use, the size of which shall be uniform and not less than ten-point with a lowercase unspaced alphabet length not less than one-hundred-twenty-point, the word “text” as herein used including all printed matter except the name and address of the insurer, name or title of the policy, the brief description, if any, and captions and subcaptions; (5) the exceptions and reductions of indemnity are set forth in the policy and, except as provided in section 38a-483, are printed, at the insurer's option, either included with the benefit provision to which they apply, or under an appropriate caption such as “EXCEPTIONS” or “EXCEPTIONS AND REDUCTIONS”, provided, if an exception or reduction specifically applies only to a particular benefit of the policy, a statement of such exception or reduction shall be included with the benefit provision to which it applies; (6) each such form, including riders and endorsements, shall be identified by a form number in the lower left-hand corner of the first page thereof; and (7) such policy contains no provision purporting to make any portion of the charter, rules, constitution or bylaws of the insurer a part of the policy unless such portion is set forth in full in the policy, except in the case of the incorporation of, or reference to, a statement of rates or classification of risks, or short-rate table filed with the commissioner.

(1949 Rev., S. 6178; 1951, S. 2836d; 1972, P.A. 127, S. 63; P.A. 90-243, S. 73; P.A. 07-185, S. 15; P.A. 14-235, S. 50.)

History: 1972 act changed maximum insurable age of children in Subsec. (a)(3) from 19 to 18, reflecting changed age of majority; P.A. 90-243 added reference to “individual health insurance” and deleted former Subsec. (b); Sec. 38-166 transferred to Sec. 38a-482 in 1991; P.A. 07-185 amended Subdiv. (3) re age of children who may be insured under adult family member's individual health insurance policy by replacing provision re specified age not to exceed 18 years with reference to Sec. 38a-497, effective July 1, 2007; P.A. 14-235 made a technical change in Subdiv. (3).

Annotation to former section 38-166:

Cited. 214 C. 303.

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Sec. 38a-482a. Individual health insurance policy to contain definition of “medically necessary” or “medical necessity”. (a) No insurer, health care center, hospital service corporation, medical service corporation or other entity delivering, issuing for delivery, renewing, continuing or amending any individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469 in this state shall deliver or issue for delivery in this state any such policy unless such policy contains a definition of “medically necessary” or “medical necessity” as follows: “Medically necessary” or “medical necessity” means health care services that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are: (1) In accordance with generally accepted standards of medical practice; (2) clinically appropriate, in terms of type, frequency, extent, site and duration and considered effective for the patient's illness, injury or disease; and (3) not primarily for the convenience of the patient, physician or other health care provider and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness, injury or disease. For the purposes of this subsection, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community or otherwise consistent with the standards set forth in policy issues involving clinical judgment.

(b) The provisions of subsection (a) of this section shall not apply to any insurer, health care center, hospital service corporation, medical service corporation or other entity that has entered into any national settlement agreement until the expiration of any such agreement.

(P.A. 07-75, S. 1; P.A. 11-19, S. 21.)

History: P.A. 07-75 effective January 1, 2008; P.A. 11-19 made technical changes.

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

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Sec. 38a-482b. Individual health insurance policy providing limited coverage to include disclosure. Limited coverage defined. (a) Each individual health insurance policy, subscriber contract or certificate of coverage delivered or issued for delivery in this state on or after January 1, 2008, that provides limited coverage, and any marketing material, application for coverage and enrollment material relative to such policy, contract or certificate, shall include the following statement printed in capital letters in not less than twelve-point boldface type and located in a conspicuous manner on such document:

“THIS LIMITED HEALTH BENEFITS PLAN DOES NOT PROVIDE COMPREHENSIVE MEDICAL COVERAGE. IT IS A BASIC OR LIMITED BENEFITS POLICY AND IS NOT INTENDED TO COVER ALL MEDICAL EXPENSES. THIS PLAN IS NOT DESIGNED TO COVER THE COSTS OF SERIOUS OR CHRONIC ILLNESS. IT CONTAINS SPECIFIC DOLLAR LIMITS THAT WILL BE PAID FOR MEDICAL SERVICES WHICH MAY NOT BE EXCEEDED. IF THE COST OF SERVICES EXCEEDS THOSE LIMITS, THE BENEFICIARY AND NOT THE INSURER IS RESPONSIBLE FOR PAYMENT OF THE EXCESS AMOUNTS. THE SPECIFIC DOLLAR LIMITS ARE AS FOLLOWS: (INSURER TO SPECIFY SUCH AMOUNTS).”

(b) For the purposes of this section, “limited coverage” means an insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 that contains an annual maximum benefit of less than one hundred thousand dollars or fixed dollar benefits of less than twenty thousand dollars on any core services. For the purpose of this section, “core services” means medical, surgical and hospital services, including inpatient and outpatient physician, laboratory and imaging services.

(P.A. 07-96, S. 1; P.A. 08-147, S. 11.)

History: P.A. 07-96 effective July 1, 2007; P.A. 08-147 redefined “limited coverage” in Subsec. (b) to specify fixed dollar benefits of less than $20,000 on any core services.

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

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Sec. 38a-482c. Annual and lifetime limits. (a) No 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 shall include an annual or lifetime limit on the dollar value of benefits for a covered individual, for covered benefits that are essential health benefits, as defined in (1) the Patient Protection and Affordable Care Act, P.L. 111-148, as amended from time to time, or regulations adopted thereunder, or (2) section 38a-492q, or regulations adopted thereunder.

(b) This section shall not prohibit the inclusion of a lifetime limit on specific covered benefits that are not essential health benefits, provided the lifetime limit for reasonable charges or, when applicable, the allowance agreed upon by a health care provider and an insurer, health care center, hospital service corporation, medical service corporation or fraternal benefit society for charges actually incurred for any specific covered benefit, shall be not less than one million dollars per covered individual.

(P.A. 11-58, S. 42; P.A. 17-15, S. 48; P.A. 18-10, S. 9.)

History: P.A. 11-58 effective July 2, 2011; P.A. 17-15 made a technical change in Subsec. (a); P.A. 18-10 amended Subsec. (a) by provision prohibiting annual limit for essential health benefits, designating existing provisions re Affordable Care Act as Subdiv. (1), and adding Subdiv. (2) prohibiting annual and lifetime limits for essential health benefits under Sec. 38a-492q or regulations adopted thereunder, effective January 1, 2019.

See Sec. 38a-512c for similar provisions re group policies.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(1949 Rev., S. 6179, 6180, 6186; Apps. B, C; 1951, S. 2837d; 1971, P.A. 267; P.A. 79-376, S. 58; P.A. 90-243, S. 74; P.A. 95-40; P.A. 10-5, S. 19; P.A. 14-235, S. 26.)

History: 1971 act replaced previous provisions re “time limit on defenses” which had detailed voidance of policy because of misstatements on application with provision stating that policy is uncontestable except for premium nonpayment after it is in force for two years; P.A. 79-376 substituted “workers' compensation” for “workmen's compensation” where appearing; P.A. 90-243 added reference to “an individual health insurance” policy; Sec. 38-167 transferred to Sec. 38a-483 in 1991; P.A. 95-40 added requirement to Subsec. (b)(8) that written notice be delivered not only to the insured but also to any dependents listed on the application and any subsequent revisions thereto; (Revisor's note: When P.A. 95-40, which amended Subsec. (b)(8) concerning “CANCELLATION”, was incorporated into the section by the Revisors, the unamended text of Subsec. (b)(8) was inadvertently moved to and replaced the then existing Subsec. (a)(8) concerning “TIME OF PAYMENT OF CLAIMS”. Since there was no legislation in 1995, or subsequently, making any changes to Subsec. (a)(8), the Revisors editorially corrected their 1995 codification error by reinstating the correct wording of Subsec. (a)(8) for the 2001 revision); P.A. 10-5 made a technical change in Subsec. (b)(6), effective May 5, 2010; P.A. 14-235 made a technical change in Subsec. (a)(8).

Annotation to former section 38-167:

Gardener setting off a single bomb on 4th of July held not to have changed occupation to a more hazardous one. 91 C. 729.

Annotation to present section:

Subsec. (a):

“Entire contract” provision does not prohibit insurer from incorporating by reference its underwriting income rules in an increase option rider to a disability insurance policy, when application of those rules can neither decrease nor eliminate a fixed benefit of original policy. 273 C. 12.

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

(June 18 Sp. Sess. P.A. 97-8, S. 71, 88; P.A. 17-15, S. 49.)

History: June 18 Sp. Sess. P.A. 97-8 effective July 1, 1997; P.A. 17-15 made a technical change.

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Sec. 38a-483b. Time limits for coverage determinations. Notice requirements. Section 38a-483b is repealed, effective October 1, 2015.

(P.A. 99-284, S. 12; P.A. 10-24, S. 1; P.A. 11-19, S. 23; P.A. 15-118, S. 71.)

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

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

(c) Any person who has been diagnosed with a condition that creates a life expectancy in that person of less than two years and who has been denied an otherwise covered procedure, treatment or drug on the grounds that it is experimental may request an expedited appeal as provided in section 38a-591e and may appeal a denial thereof to the Insurance Commissioner in accordance with the procedures established in section 38a-591g.

(P.A. 99-284, S. 15, 60; P.A. 11-58, S. 81; P.A. 12-145, S. 43.)

History: P.A. 99-284 effective January 1, 2000; P.A. 11-58 amended Subsec. (c) to replace references to Secs. 38a-226c and 38a-478n with “section 38a-591e” and “section 38a-591g”, respectively, and deleted former Subsec. (d) re appeal of a procedure, treatment or drug denied on grounds that such procedure, treatment or drug is experimental, effective July 1, 2011; P.A. 12-145 amended Subsec. (a) to delete “on or after January 1, 2000”, effective June 15, 2012.

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

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

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

(1949 Rev., S. 6185; 1951, S. 2838d; P.A. 14-235, S. 27.)

History: Sec. 38-168 transferred to Sec. 38a-484 in 1991; P.A. 14-235 made a technical change in Subsec. (a).

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

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

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

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

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

Annotation to former section 38-169:

Cited. 214 C. 303.

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

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

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

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

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

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

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

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

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

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

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

See Sec. 38a-816 re unfair practices.

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(1) (A) “Mental or nervous conditions” means mental disorders, as defined in the most recent edition of the American Psychiatric Association's “Diagnostic and Statistical Manual of Mental Disorders”.

(B) “Mental or nervous conditions” does not include (i) intellectual disability, (ii) specific learning disorders, (iii) motor disorders, (iv) communication disorders, (v) caffeine-related disorders, (vi) relational problems, and (vii) other conditions that may be a focus of clinical attention, that are not otherwise defined as mental disorders in the most recent edition of the American Psychiatric Association's “Diagnostic and Statistical Manual of Mental Disorders”.

(2) “Benefits payable” means the usual, customary and reasonable charges for treatment deemed necessary under generally accepted medical standards, except that in the case of a managed care plan, as defined in section 38a-478, “benefits payable” means the payments agreed upon in the contract between a managed care organization, as defined in section 38a-478, and a provider, as defined in section 38a-478.

(3) “Acute treatment services” means twenty-four-hour medically supervised treatment for a substance use disorder, that is provided in a medically managed or medically monitored inpatient facility.

(4) “Clinical stabilization services” means twenty-four-hour clinically managed postdetoxification treatment, including, but not limited to, relapse prevention, family outreach, aftercare planning and addiction education and counseling.

(b) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide benefits for the diagnosis and treatment of mental or nervous conditions. Benefits payable include, but need not be limited to:

(1) General inpatient hospitalization, including in state-operated facilities;

(2) Medically necessary acute treatment services and medically necessary clinical stabilization services;

(3) General hospital outpatient services, including at state-operated facilities;

(4) Psychiatric inpatient hospitalization, including in state-operated facilities;

(5) Psychiatric outpatient hospital services, including at state-operated facilities;

(6) Intensive outpatient services, including at state-operated facilities;

(7) Partial hospitalization, including at state-operated facilities;

(8) Intensive, home-based or evidence-based services designed to address specific mental or nervous conditions in a child or adolescent;

(9) Evidence-based family-focused therapy that specializes in the treatment of juvenile substance use disorders;

(10) Short-term family therapy intervention;

(11) Nonhospital inpatient detoxification;

(12) Medically monitored detoxification;

(13) Ambulatory detoxification;

(14) Inpatient services at psychiatric residential treatment facilities;

(15) Rehabilitation services provided in residential treatment facilities, general hospitals, psychiatric hospitals or psychiatric facilities;

(16) Observation beds in acute hospital settings;

(17) Psychological and neuropsychological testing conducted by an appropriately licensed health care provider;

(18) Trauma screening conducted by a licensed behavioral health professional;

(19) Depression screening, including maternal depression screening, conducted by a licensed behavioral health professional;

(20) Substance use screening conducted by a licensed behavioral health professional;

(c) No such policy shall establish any terms, conditions or benefits that place a greater financial burden on an insured for access to diagnosis or treatment of mental or nervous conditions than for diagnosis or treatment of medical, surgical or other physical health conditions, or prohibit an insured from obtaining or a health care provider from being reimbursed for multiple screening services as part of a single-day visit to a health care provider or a multicare institution, as defined in section 19a-490.

(d) In the case of benefits payable for the services of a licensed physician, such benefits shall be payable for the same services when such services are lawfully rendered by a psychologist licensed under the provisions of chapter 383 or by such a licensed psychologist in a licensed hospital or clinic or an advanced practice registered nurse licensed under the provisions of chapter 378.

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

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

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

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

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

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

(6) A licensed professional counselor; or

(7) An advanced practice registered nurse licensed under the provisions of chapter 378.

(f) (1) In the case of benefits payable for the services of a licensed physician, such benefits shall be payable for (A) services rendered in a child guidance clinic or residential treatment facility by a person with a master's degree in social work or by a person with a master's degree in marriage and family therapy under the supervision of a psychiatrist, physician, licensed marital and family therapist, or licensed clinical social worker who is eligible for reimbursement under subdivisions (1) to (4), inclusive, of subsection (e) of this section; (B) services rendered in a residential treatment facility by a licensed or certified alcohol and drug counselor who is eligible for reimbursement under subdivision (5) of subsection (e) of this section; (C) services rendered in a residential treatment facility by a licensed professional counselor who is eligible for reimbursement under subdivision (6) of subsection (e) of this section; or (D) services rendered in a residential treatment facility by a licensed advanced practice registered nurse who is eligible for reimbursement under subdivision (7) of subsection (e) of this section.

(2) In the case of benefits payable for the services of a licensed psychologist under subsection (e) of this section, such benefits shall be payable for (A) services rendered in a child guidance clinic or residential treatment facility by a person with a master's degree in social work or by a person with a master's degree in marriage and family therapy under the supervision of such licensed psychologist, licensed marital and family therapist, or licensed clinical social worker who is eligible for reimbursement under subdivisions (1) to (4), inclusive, of subsection (e) of this section; (B) services rendered in a residential treatment facility by a licensed or certified alcohol and drug counselor who is eligible for reimbursement under subdivision (5) of subsection (e) of this section; (C) services rendered in a residential treatment facility by a licensed professional counselor who is eligible for reimbursement under subdivision (6) of subsection (e) of this section; or (D) services rendered in a residential treatment facility by a licensed advanced practice registered nurse who is eligible for reimbursement under subdivision (7) of subsection (e) of this section.

(g) In the case of benefits payable for the service of a licensed physician practicing as a psychiatrist or a licensed psychologist, under subsection (e) of this section, such benefits shall be payable for outpatient services rendered (1) in a nonprofit community mental health center, as defined by the Department of Mental Health and Addiction Services, in a nonprofit licensed adult psychiatric clinic operated by an accredited hospital or in a residential treatment facility; (2) under the supervision of a licensed physician practicing as a psychiatrist, a licensed psychologist, a licensed marital and family therapist, a licensed clinical social worker, a licensed or certified alcohol and drug counselor, a licensed professional counselor or a licensed advanced practice registered nurse who is eligible for reimbursement under subdivisions (1) to (7), inclusive, of subsection (e) of this section; and (3) within the scope of the license issued to the center or clinic by the Department of Public Health or to the residential treatment facility by the Department of Children and Families.

(h) Except in the case of emergency services, services rendered to an insured at an urgent crisis center, as defined in section 38a-477aa, or services for which an individual has been referred by a physician or an advanced practice registered nurse affiliated with a health care center, nothing in this section shall be construed to require a health care center to provide benefits under this section through facilities that are not affiliated with the health care center.

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

(j) Reimbursement for covered services rendered in this state by an out-of-network health care provider for the diagnosis or treatment of a substance use disorder shall be paid under the insured's individual health insurance policy directly to the provider if the provider is otherwise eligible for reimbursement for such services. The insured who received such services shall be deemed to have made an assignment to such provider of such insured's coverage reimbursement benefits and other rights under the policy. In no event shall such provider bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from or have any recourse against the insured for such services, except that such provider may collect any copayments, deductibles or other out-of-pocket expenses that the insured is required to pay under the policy.

(June 18 Sp. Sess. P.A. 97-8, S. 63, 88; P.A. 99-284, S. 27, 60; P.A. 00-135, S. 10, 21; P.A. 02-24, S. 6; P.A. 07-73, S. 2(a); P.A. 12-145, S. 45; P.A. 13-84, S. 3; 13-139, S. 33; P.A. 14-235, S. 57; P.A. 15-226, S. 1; June Sp. Sess. P.A. 15-5, S. 43, 44; P.A. 17-9, S. 3; 17-157, S. 1; June Sp. Sess. P.A. 17-2, S. 202; P.A. 18-68, S. 10; P.A. 19-98, S. 8; P.A. 22-47, S. 43, 53.)

History: June 18 Sp. Sess. P.A. 97-8 effective July 1, 1997; P.A. 99-284 rewrote Subsec. (a) and referenced Subdivs. (1), (2), (4), (11) and (12) of Sec. 38a-469, deleted reference to biologically-based mental or nervous conditions and definition thereof and replaced with provision for coverage of the diagnosis and treatment of mental or nervous conditions, and defined “mental or nervous conditions”, added new Subsec. (b) re prohibition on terms, conditions or benefits that place a greater financial burden on insured re mental or nervous conditions than for other conditions, added new Subsec. (c) re benefits payable when rendered by a psychologist, added new Subsec. (d) re benefits payable for enumerated providers, added new Subsec. (e) to define “covered expenses”, added new Subsec. (f) re benefits payable for services rendered in certain facilities, added new Subsec. (g) re certain outpatient benefits, added new Subsec. (h) re benefits provided by a health care center, and added new Subsec. (i) re state liens against certain coverage proceeds, effective January 1, 2000; P.A. 00-135 reorganized section and added provisions re licensed professional counselors, effective May 26, 2000; P.A. 02-24 deleted “the” re “post-master's social work experience” in Subsec. (d)(1) and (3); pursuant to P.A. 07-73 “Department of Mental Retardation” was changed editorially by the Revisors to “Department of Developmental Services”, effective October 1, 2007; P.A. 12-145 amended Subsec. (a) to delete “on or after January 1, 2000”, effective June 15, 2012; P.A. 13-84 amended Subsec. (a) by adding provision re coverage for insured diagnosed with autism spectrum disorder prior to release of the fifth edition of the American Psychiatric Association's “Diagnostic and Statistical Manual of Mental Disorders”, effective June 5, 2013; P.A. 13-139 amended Subsec. (a)(1) by substituting “intellectual disability” for “mental retardation”; P.A. 14-235 amended Subsec. (a) to replace “disability” with “disabilities” in Subdiv. (1), add “specific” in Subdiv. (2), delete “skills” in Subdiv. (3) and replace “additional” with “other” in Subdiv. (7); P.A. 15-226 amended Subsec. (a) by deleting provisions re insurance policy and coverage for insured diagnosed with autism spectrum disorder prior to release of 5th edition of American Psychiatric Association's “Diagnostic and Statistical Manual of Mental Disorders”, adding definitions of “benefits payable”, “acute treatment services” and “clinical stabilization services”, and making technical changes, added new Subsec. (b) re coverage requirements, redesignated existing Subsec. (b) as Subsec. (c) and amended same by adding provision re policy not to prohibit insured from obtaining or health care provider from being reimbursed for multiple screening services, redesignated existing Subsec. (c) as Subsec. (d), redesignated existing Subsec. (d) as Subsec. (e) and amended same by adding Subdiv. (7) re advanced practice registered nurse, deleted former Subsec. (e) re definition of “covered expenses”, and made conforming changes in Subsecs. (f) and (g), effective January 1, 2016; June Sp. Sess. P.A. 15-5 amended Subsec. (b) by deleting reference to problematic parenting practices and other family and educational challenges in Subdiv. (9), deleting former Subdiv. (10) re coverage for intensive, family-based and community-based treatment programs, redesignating existing Subdiv. (11) as Subdiv. (10) and amending same to delete “and delinquency”, redesignating existing Subdiv. (12) as Subdiv. (11) and amending same to delete provision re juvenile diversion programs, deleting former Subdivs. (13), (14) and (19) re coverage for other home-based therapeutic interventions for children, chemical maintenance treatment and extended day treatment programs, and redesignating existing Subdivs. (15) to (18) and (20) to (25) as Subdivs. (12) to (21), effective January 1, 2016, and further amended Subsec. (b) by adding Subdivs. (22) to (25) re coverage for intensive, family-based and community-based treatment programs, other home-based therapeutic interventions for children, chemical maintenance treatment and extended day treatment programs, effective January 1, 2017; P.A. 17-9 amended Subsec. (a)(1)(A) by replacing “disabilities” with “disability”; P.A. 17-157 added Subsec. (j) re reimbursement to out-of-network health care provider for diagnosis or treatment of substance use disorder, effective January 1, 2018; June Sp. Sess. P.A. 17-2 amended Subsec. (b) by deleting former Subdiv. (8) re maternal, infant and early childhood home visitation services, redesignating existing Subdivs. (9) to (21) as Subdivs. (8) to (20) and deleting former Subdivs. (22) to (25) re intensive, family-based and community-based treatment programs, other home-based therapeutic interventions for children, chemical maintenance treatment and extended day treatment programs, respectively, effective October 31, 2017; P.A. 18-68 made a technical change in Subsec. (e)(7); P.A. 19-98 amended Subsecs. (d), (g)(2) and (h) by adding references to advanced practice registered nurse, amended Subsecs. (f)(1) and (f)(2) by adding Subpara. (D) re services rendered in residential treatment facility by an advanced practice registered nurse and made technical and conforming changes; P.A. 22-47 amended Subsec. (a) by making technical changes, designating existing provisions as Subdiv. (1)(A) and (1)(B), designating existing Subparas. (A) to (G) as clauses (i) to (vii), amended Subsec.(b)(8) by adding “or evidence-based” and “or adolescent”, and amended Subsec. (h) by adding urgent crisis center services as an exception, effective January 1, 2023.

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

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Sec. 38a-488b. Coverage for autism spectrum disorder therapies. (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 spectrum disorder services provider” means any person, entity or group that provides treatment for an autism spectrum disorder pursuant to this section.

(3) “Autism spectrum disorder” means “autism spectrum disorder” as set forth in the most recent edition of the American Psychiatric Association's “Diagnostic and Statistical Manual of Mental Disorders”.

(4) “Behavioral therapy” means any interactive behavioral therapies derived from evidence-based research and consistent with the services and interventions designated by the Commissioner of Social Services pursuant to subsection (l) of section 17a-215c, 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 autism spectrum disorder, that are: (A) Provided to children less than twenty-one years of age; and (B) provided or supervised by (i) a licensed behavior analyst, (ii) a licensed physician, or (iii) a licensed psychologist. For the purposes of this subdivision, behavioral therapy is “supervised by” such licensed behavior analyst, licensed physician or licensed psychologist when such supervision entails at least one hour of face-to-face supervision of the autism spectrum disorder services provider by such licensed 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 autism spectrum disorder.

(b) 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 shall provide coverage for the diagnosis and treatment of autism spectrum disorder. For the purposes of this section and section 38a-482a, 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 autism spectrum disorder, in accordance with a treatment plan developed by a licensed behavior analyst, 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, a licensed physician assistant or an advanced practice registered nurse for the treatment of symptoms and comorbidities of autism spectrum disorder;

(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 shall not impose (1) any limits on the number of visits an insured may make to an autism spectrum disorder 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 autism spectrum disorder than for the diagnosis and treatment of any other medical, surgical or physical health condition under such policy.

(e) (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.

(f) Coverage required under this section may be subject to the other general exclusions and limitations of the individual 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 (e) of this section.

(g) (1) Nothing in this section shall be construed to limit or affect (A) any other covered benefits available to an insured under (i) such individual health insurance policy, (ii) section 38a-488a, or (iii) section 38a-490a, (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 individual 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. 1; P.A. 11-4, S. 6; P.A. 13-84, S. 1; June Sp. Sess. P.A. 15-5, S. 348; May Sp. Sess. P.A. 16-3, S. 55; June Sp. Sess. P.A. 17-2, S. 197.)

History: P.A. 08-132 effective January 1, 2009; P.A. 11-4 substituted “autism spectrum disorder” for “autism spectrum disorders”, effective May 9, 2011; P.A. 13-84 designated existing provisions as Subsec. (a) and amended same by adding provision re coverage for insured diagnosed with autism spectrum disorder prior to release of the fifth edition of the American Psychiatric Association's “Diagnostic and Statistical Manual of Mental Disorders” and by making a technical change, and added Subsec. (b) re same coverage provision, effective June 5, 2013; June Sp. Sess. P.A. 15-5 added new Subsec. (a) defining “applied behavior analysis”, “autism spectrum disorder services provider”, “autism spectrum disorder”, “behavioral therapy”, and “diagnosis”, redesignated existing Subsec. (a) as Subsec. (b) and amended same to add “diagnosis and”, delete references to physical therapy, speech therapy and occupational therapy services and the American Psychiatric Association's “Diagnostic and Statistical Manual of Mental Disorders”, delete provisions re limitation on coverage and add provision re autism spectrum disorder to be considered an illness, deleted former Subsec. (b) re maintaining coverage, added Subsec. (c) re coverage for treatments, added Subsec. (d) re prohibition on imposing limits on visits or out-of-pocket expenses, added Subsec. (e) re review of treatment plan and time period of validity of diagnostic results, added Subsec. (f) re exclusions from and limitations on coverage, and added Subsec. (g) re other covered benefits, obligations to provide services and obligations imposed on public schools and re reimbursement for special education and related services, effective January 1, 2016; May Sp. Sess. P.A. 16-3 amended Subsec. (a)(4) to replace “Commissioner of Developmental Services” with “Commissioner of Social Services”, effective July 1, 2016; June Sp. Sess. P.A. 17-2 amended Subsecs. (a)(4) and (c) to add references to licensed behavior analyst and delete references to certification of behavior analyst by Behavior Analyst Certification Board, effective July 1, 2018.

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

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Sec. 38a-488c. Mental health and substance use disorder benefits. Nonquantitative treatment limitations. No individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state on or after January 1, 2020, shall apply a nonquantitative treatment limitation to mental health and substance use disorder benefits unless such policy applies such limitation to such benefits in a manner that is comparable to, and not more stringent than, the manner in which such policy applies such limitation to medical and surgical benefits. For the purposes of this section, “nonquantitative treatment limitation” and “mental health and substance use disorder benefits” have the same meaning as provided in section 38a-477ee.

(P.A. 19-159, S. 2.)

History: P.A. 19-159 effective January 1, 2020.

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

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Sec. 38a-488d. Coverage for substance abuse services provided pursuant to court order. No 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, 2020, shall deny coverage for covered substance abuse services solely because such substance abuse services were provided pursuant to an order issued by a court of competent jurisdiction.

(P.A. 19-159, S. 4.)

History: P.A. 19-159 effective January 1, 2020.

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

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Sec. 38a-488e. Coverage for mental health wellness examinations. (a) For the purposes of this section:

(1) “Licensed mental health professional” means: (A) A licensed professional counselor or professional counselor, both as defined in section 20-195aa; (B) a person who is under professional supervision, as defined in section 20-195aa; (C) a physician licensed pursuant to chapter 370, who is certified in psychiatry by the American Board of Psychiatry and Neurology; (D) an advanced practice registered nurse licensed pursuant to chapter 378, who is certified as a psychiatric and mental health clinical nurse specialist or nurse practitioner by the American Nurses Credentialing Center; (E) a psychologist licensed pursuant to chapter 383; (F) a marital and family therapist licensed pursuant to chapter 383a; (G) a licensed clinical social worker licensed pursuant to chapter 383b; or (H) an alcohol and drug counselor licensed under chapter 376b;

(2) “Mental health wellness examination” means a screening or assessment that seeks to identify any behavioral or mental health needs and appropriate resources for treatment. The examination may include: (A) Observation; (B) a behavioral health screening; (C) education and consultation on healthy lifestyle changes; (D) referrals to ongoing treatment, mental health services and other necessary supports; (E) discussion of potential options for medication; (F) age-appropriate screenings or observations to understand the mental health history, personal history and mental or cognitive state of the person being examined; and (G) if appropriate, relevant input from an adult through screenings, interviews or questions;

(3) “Primary care provider” has the same meaning as provided in section 19a-7o; and

(4) “Primary care” has the same meaning as provided in section 19a-7o.

(b) (1) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 and delivered, issued for delivery, renewed, amended or continued in this state on or after January 1, 2023, (A) shall provide coverage for two mental health wellness examinations per year that are performed by a licensed mental health professional or primary care provider, and (B) shall not require prior authorization of such examinations.

(2) The mental health wellness examinations: (A) May each be provided by a primary care provider as part of a preventive visit; and (B) shall be covered with no patient cost-sharing.

(c) The provisions of this section shall apply to a high deductible health plan, as that term is used in subsection (f) of section 38a-493, to the maximum extent permitted by federal law, except if such plan is used to establish a medical savings account or an Archer MSA pursuant to Section 220 of the Internal Revenue Code of 1986, as amended from time to time, or any subsequent corresponding Internal Revenue Code of the United States, as amended from time to time, or a health savings account pursuant to Section 223 of said Internal Revenue Code of 1986, as amended from time to time, the provisions of this section shall apply to such plan to the maximum extent that (1) is permitted by federal law, and (2) does not disqualify such account for the deduction allowed under said Section 220 or 223, as applicable.

(P.A. 22-47, S. 41.)

History: P.A. 22-47 effective January 1, 2023.

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Sec. 38a-488f. Coverage for services provided under the Collaborative Care Model. (a) For the purposes of this section:

(1) “Collaborative Care Model” means the integrated delivery of behavioral health and primary care services by a primary care team that includes a primary care provider, a behavioral care manager, a psychiatric consultant and a database used by the behavioral care manager to track patient progress;

(2) “CPT code” means a code number under the Current Procedural Terminology system developed by the American Medical Association; and

(3) “HCPCS code” means a code number under the Healthcare Common Procedure Coding System developed by the federal Centers for Medicare and Medicaid Services.

(b) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 and delivered, issued for delivery, renewed, amended or continued in this state on or after January 1, 2023, shall provide coverage for health care services that a primary care provider provides to an insured under the Collaborative Care Model. Such services shall include, but need not be limited to, services with a CPT code of 99484, 99492, 99493 or 99494 or HCPCS code of G2214, or any subsequent corresponding code.

(P.A. 22-47, S. 47.)

History: P.A. 22-47 effective January 1, 2023.

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Sec. 38a-488g. Acute inpatient psychiatric coverage. Prior authorization not required. (a) No individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state on or after January 1, 2023, that provides coverage for acute inpatient psychiatric services shall require prior authorization for such services that are provided to an insured: (1) Following the insured's admission to a hospital emergency department; (2) upon the referral of the insured's treating physician licensed pursuant to chapter 370, psychologist licensed pursuant to chapter 383 or advanced practice registered nurse licensed pursuant to chapter 378 if (A) there is imminent danger to the insured's health or safety, or (B) the insured poses an imminent danger to the health or safety of others; or (3) at an urgent crisis center, as defined in section 38a-477aa. Nothing in this section shall preclude a health carrier from using other forms of utilization review, including, but not limited to, concurrent and retrospective review.

(b) Any health care provider who refers an insured for the acute inpatient psychiatric services described in subsection (a) of this section shall provide to the insured, at the time of such referral, a written notice disclosing that the insured may: (1) Incur out-of-pocket costs if such services are not covered by such insured's health insurance policy; and (2) choose to wait for an in-network bed for such services or risk incurring costs for out-of-network care if such services are provided on an out-of-network basis.

(c) Any health care provider who provides the acute inpatient psychiatric services described in subsection (a) of this section shall provide to the insured, at the time the insured is admitted for such services, a written notice disclosing to the insured that the insured may: (1) Incur out-of-pocket costs if such services are not covered by such insured's health insurance policy; and (2) choose to wait for an in-network bed for such services or risk incurring costs for out-of-network care if such services are provided on an out-of-network basis.

(d) The provisions of this section shall apply to a high deductible health plan, as that term is used in subsection (f) of section 38a-493, to the maximum extent permitted by federal law, except if such plan is used to establish a medical savings account or an Archer MSA pursuant to Section 220 of the Internal Revenue Code of 1986, or any subsequent corresponding internal revenue code of the United States, as amended from time to time, or a health savings account pursuant to Section 223 of said Internal Revenue Code, as amended from time to time, the provisions of this section shall apply to such plan to the maximum extent that (1) is permitted by federal law; and (2) does not disqualify such account for the deduction allowed under said Section 220 or 223, as applicable.

(P.A. 22-47, S. 55.)

History: P.A. 22-47 effective January 1, 2023.

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Sec. 38a-489. (Formerly Sec. 38-174e). Continuation of coverage of mentally or physically handicapped children. 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 that provides that coverage of a dependent child shall terminate upon attainment of the limiting age for dependent children specified in the policy shall also provide in substance that attainment of the limiting age shall not operate to terminate the coverage of the child if at such date the child is and continues thereafter to be both (1) incapable of self-sustaining employment by reason of mental or physical handicap, as certified by the child's physician, physician assistant or advanced practice registered nurse on a form provided by the insurer, hospital service corporation, medical service corporation or health care center, and (2) chiefly dependent upon the policyholder or subscriber for support and maintenance.

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

(1971, P.A. 408, S. 1, 2; P.A. 87-207, S. 1; P.A. 90-243, S. 79; P.A. 11-19, S. 33; P.A. 15-118, S. 4; P.A. 16-39, S. 57; P.A. 17-15, S. 50; P.A. 21-196, S. 62.)

History: P.A. 87-207 amended Subsecs. (a) and (b) to provide that for individual and group policies the continuation rights for children are applicable if the child is incapable of employment by reason of mental or physical handicap which has been certified by the child's physician; P.A. 90-243 substituted reference to “health insurance policy” for reference to hospital or medical expense policies and contracts, divided former Subsec. (a) into Subsecs. (a) and (b), added a reference to “health care center” and deleted former Subsec. (b) re group policies; Sec. 38-174e transferred to Sec. 38a-489 in 1991; P.A. 11-19 inserted “renewed, amended or continued” and made technical changes in Subsec. (a), effective January 1, 2012; P.A. 15-118 made technical changes; P.A. 16-39 amended Subsec. (a)(1) by adding reference to advanced practice registered nurse; P.A. 17-15 amended Subsec. (a) to delete “more than one hundred twenty days after July 1, 1971,”; P.A. 21-196 amended Subsec. (a) by adding reference to physician assistant.

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

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Sec. 38a-490. (Formerly Sec. 38-174g). Coverage for newly born children. Notification to insurer. (a) Each individual health insurance policy delivered, issued for delivery, renewed, amended or continued in this state providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469 for a family member of the insured or subscriber shall, as to such family member's coverage, also provide that the health insurance benefits applicable for children shall be payable with respect to a newly born child of the insured or subscriber from the moment of birth.

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

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

(P.A. 74-6, S. 1–4; P.A. 90-243, S. 80; P.A. 11-19, S. 35; 11-171, S. 3; P.A. 12-145, S. 12.)

History: P.A. 90-243 substituted references to “health insurance policies” for references to hospital and medical expense policies and contracts, specified applicability to individual policies only, and applied provisions to “health care centers”; Sec. 38-174g transferred to Sec. 38a-490 in 1991; P.A. 11-19 inserted “delivered, issued for delivery, renewed, amended or continued in this state” and made a technical change in Subsec. (a), made technical changes in Subsec. (c), and deleted former Subsec. (d) re application of section to policies delivered or issued for delivery on or after October 1, 1974, or amended or renewed, effective January 1, 2012; P.A. 11-171 inserted “delivered, issued for delivery, renewed, amended or continued in this state” and made a technical change in Subsec. (a), increased time period for insured to notify insurer of birth of child and pay required premium or fee from 31 days to 61 days after birth and made technical changes in Subsec. (c), and deleted former Subsec. (d) re application of section to policies delivered or issued for delivery on or after October 1, 1974, or amended or renewed, effective January 1, 2012; P.A. 12-145 made a technical change in Subsec. (a), effective June 15, 2012.

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

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Sec. 38a-490a. Coverage for birth-to-three program. (a) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state 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 coverage for such services provided by qualified personnel, as defined in section 17a-248, for eligible children, as defined in section 17a-248.

(b) No such policy shall impose a coinsurance, copayment, deductible or other out-of-pocket expense for such services, except that a high deductible health plan, as that term is used in subsection (f) of section 38a-493, shall not be subject to the deductible limits set forth in this section.

(c) No payment made under this section shall (1) adversely affect the availability of health insurance to the child, the child's parent or the child's family members insured under any such policy, or (2) be a reason for the insurer, health care center or plan administrator to rescind or cancel such policy. Payments made under this section shall not be treated differently than other claim experience for purposes of premium rating.

(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; P.A. 11-44, S. 147; P.A. 12-44, S. 1; P.A. 13-84, S. 5; P.A. 14-235, S. 18; June Sp. Sess. P.A. 15-5, S. 350; P.A. 18-68, S. 11; July Sp. Sess. P.A. 20-4, S. 16; June Sp. Sess. P.A. 21-2, S. 420.)

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; P.A. 11-44 added provision prohibiting out-of-pocket expenses with exception for high deductible plans, deleted Subdiv. (1) and (2) designators and made technical changes, effective January 1, 2012; P.A. 12-44 designated existing provisions as Subsecs. (a) to (d), amended Subsec. (a) to add “amended or continued” and delete “on or after July 1, 1996”, amended Subsec. (d) to add provisions re restrictions on treatment of payment, and made technical changes, effective July 1, 2012; P.A. 13-84 amended Subsec. (a) by designating existing provision re coverage for services provided by qualified personnel as Subdiv. (1) and adding Subdiv. (2) re coverage for insured diagnosed with autism spectrum disorder prior to release of the fifth edition of the American Psychiatric Association's “Diagnostic and Statistical Manual of Mental Disorders”, effective June 5, 2013; P.A. 14-235 made a technical change in Subsec. (b); June Sp. Sess. P.A. 15-5 amended Subsec. (a) by deleting former Subdiv. (2) re level of coverage and making a conforming change, deleted former Subsec. (c) re maximum and aggregate benefit, and redesignated existing Subsec. (d) as Subsec. (c) and amended same to delete former Subdiv. (1) re loss of benefits due to maximum lifetime or annual limits, redesignate existing Subdiv. (2) as Subdiv. (1) and redesignate existing Subdiv. (3) as Subdiv. (2), effective January 1, 2016; P.A. 18-68 made a technical change in Subsec. (b); July Sp. Sess. P.A. 20-4 amended Subsec. (b) by substituting “high deductible health plan” for “high deductible plan”; June Sp. Sess. P.A. 21-2 amended Subsec. (a) by replacing “a child from birth until the child's third birthday” with “eligible children, as defined in section 17a-248”, effective July 1, 2021.

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

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

(P.A. 01-171, S. 15; P.A. 12-145, S. 47; P.A. 19-133, S. 1.)

History: P.A. 12-145 deleted “on or after October 1, 2001”, effective June 15, 2012; P.A. 19-133 deleted reference to children 12 years of age or younger and substituted provision restricting benefit to 1 hearing aid per ear within 24-month period for provision restricting benefit to $1,000 within 24-month period, effective January 1, 2020.

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

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

(P.A. 03-37, S. 1.)

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

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Sec. 38a-490d. Mandatory coverage for blood lead screening and risk assessment. 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, 2009, shall provide coverage for blood lead screening and risk assessments ordered by a primary care provider pursuant to section 19a-111g.

(June Sp. Sess. P.A. 07-2, S. 51.)

History: June Sp. Sess. P.A. 07-2 effective January 1, 2009.

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

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

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

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

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

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

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

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

(P.A. 99-284, S. 40, 60; P.A. 00-135, S. 13, 21; P.A. 03-58, S. 1; P.A. 10-5, S. 20.)

History: P.A. 99-284 effective January 1, 2000; P.A. 00-135 added outpatient or one-day dental services, effective May 26, 2000; P.A. 03-58 divided existing provisions into Subsecs. (a) and (b) and deleted “a child under the age of four who is” in Subsec. (a)(2)(A); P.A. 10-5 made technical changes in Subsec. (a), effective January 1, 2011.

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

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

(P.A. 00-33, S. 1, 3; P.A. 11-19, S. 25.)

History: P.A. 00-33 effective July 1, 2000; P.A. 11-19 made technical changes.

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

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

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

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

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

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Sec. 38a-492a. Mandatory coverage for hypodermic needles and syringes. 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 shall provide coverage for hypodermic needles or syringes prescribed by a prescribing practitioner, as defined in subdivision (28) of section 20-571, for the purpose of administering medications for medical conditions, provided such medications are covered under the policy. Such benefits shall be subject to any policy provisions that apply to other services covered by such policy.

(P.A. 92-185, S. 4, 6; P.A. 95-264, S. 62; P.A. 11-19, S. 37; July Sp. Sess. P.A. 20-4, S. 9; P.A. 21-192, S. 10.)

History: P.A. 95-264 substituted “prescribing practitioner” for “licensed practitioner” (Revisor's note: The reference to “prescribing practitioner, as defined in subdivision (21) of ...” was changed editorially by the Revisors to “prescribing practitioner, as defined in subdivision (22) of ...”); P.A. 11-19 inserted “amended or continued” and made technical changes, effective January 1, 2012; July Sp. Sess. P.A. 20-4 substituted reference to Sec. 20-571(24) for reference to Sec. 20-571(22), effective January 1, 2021; P.A. 21-192 substituted reference to Sec. 20-571(28) for reference to Sec. 20-571(24), effective July 13, 2021.

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

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Sec. 38a-492b. Coverage for certain off-label drug prescriptions. (a)(1) Each individual health insurance policy delivered, issued for delivery, renewed, amended or continued in this state, that provides coverage for prescription drugs approved by the federal Food and Drug Administration for treatment of certain types of cancer or disabling or life-threatening chronic diseases, shall not exclude coverage of any such drug on the basis that such drug has been prescribed for the treatment of a type of cancer or a disabling or life-threatening chronic disease for which the drug has not been approved by the federal Food and Drug Administration, provided the drug is recognized for treatment of the specific type of cancer or a disabling or life-threatening chronic disease for which the drug has been prescribed in one of the following established reference compendia or in peer-reviewed medical literature generally recognized by the relevant medical community: (A) The U.S. Pharmacopoeia Drug Information Guide for the Health Care Professional; (B) The American Medical Association's Drug Evaluations; or (C) The American Society of Health-System Pharmacists' American Hospital Formulary Service Drug Information. As used in this section, “peer-reviewed medical literature” means a published study in a journal or other publication in which original manuscripts have been critically reviewed for scientific accuracy, validity and reliability by unbiased international experts, and that has been determined by the International Committee of Medical Journal Editors to have met its Uniform Requirements for Manuscripts Submitted to Biomedical Journals. “Peer-reviewed medical literature” does not include publications or supplements to publications that are sponsored to a significant extent by a pharmaceutical manufacturing company or any health insurer, health care center, hospital service corporation, medical service corporation or fraternal benefit society that delivers, issues for delivery, renews, amends or continues a health insurance policy in this state.

(2) The coverage required under subdivision (1) of this subsection shall include medically necessary services associated with the administration of such drug.

(3) A drug use covered under subdivision (1) of this subsection shall not be denied based on medical necessity except for reasons that are unrelated to the legal status of the drug use.

(b) Nothing in subsection (a) of this section shall be construed to require coverage for (1) any drug used in a research trial sponsored by a drug manufacturer or a government entity, (2) any drug or service furnished in a research trial if the research trial sponsor furnishes the drug or service to an insured participating in such trial without charge, or (3) any drug that the federal Food and Drug Administration has determined to be contraindicated for treatment of the specific type of cancer or disabling or life-threatening chronic disease for which the drug has been prescribed.

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

(P.A. 94-49, S. 2; P.A. 11-19, S. 39; 11-172, S. 15; June Sp. Sess. P.A. 15-5, S. 469.)

History: P.A. 11-19 amended Subsec. (a) to add “amended or continued” and make technical changes, effective January 1, 2012; P.A. 11-172 amended Subsec. (a) to add “amended or continued”, add provisions re disabling or life-threatening chronic disease and make technical changes, amended Subsec. (b) to add provision re disabling or life-threatening chronic disease and amended Subsec. (c) to add “Except as specified”, effective January 1, 2012; June Sp. Sess. P.A. 15-5 amended Subsec. (a) by designating existing provisions re coverage for off-label prescriptions as Subdiv. (1) and amending same to add provisions re peer-reviewed medical literature, and adding Subdivs. (2) and (3) re coverage for medically necessary services and denial of drug use for reasons unrelated to legal status of the drug use, and amended Subsec. (b) by deleting “experimental or investigational drugs or”, designating existing provision re drug that Food and Drug Administration has determined to be contraindicated as Subdiv. (3), and adding Subdivs. (1) and (2) re drug used in research trial sponsored by drug manufacturer or government entity and drug or service furnished in research trial if sponsor furnishes drug or service without charge, and made technical and conforming changes, effective January 1, 2016.

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

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

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

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

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

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

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

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

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

(P.A. 97-167, S. 1; P.A. 01-101, S. 1; P.A. 04-173, S. 1: P.A. 07-197, S. 1; P.A. 12-145, S. 54.)

History: P.A. 01-101 defined, in new Subsec. (a)(4), and added coverage, in new Subsec. (c), for specialized formula; P.A. 04-173 amended Subsec. (a)(1) and (4) to redefine “inherited metabolic disease” to include cystic fibrosis and redefine “specialized formula” to include formula for children up to age 8, instead of age 3, and added Subsec. (d) to require coverage on the same basis as for outpatient prescription drugs; P.A. 07-197 amended Subsec. (a)(4) to redefine “specialized formula” to include formula for children up to age 12, instead of age 8, and amended Subsec. (c) to require coverage to be applicable to policies delivered, issued for delivery or renewed in this state on or after October 1, 2007; P.A. 12-145 amended Subsecs. (b) and (c) to delete references to Sec. 38a-469(6), add “amended or continued” re policy and delete 1997 and 2007 date references, effective January 1, 2013.

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

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Sec. 38a-492d. Mandatory coverage for diabetes screening, testing and treatment. (a) For the purposes of this section:

(1) “Diabetes device” has the same meaning as provided in section 20-616;

(2) “Diabetic ketoacidosis device” has the same meaning as provided in section 20-616;

(3) “Glucagon drug” has the same meaning as provided in section 20-616;

(4) “High deductible health plan” has the same meaning as that term is used in subsection (f) of section 38a-493;

(5) “Insulin drug” has the same meaning as provided in section 20-616;

(6) “Noninsulin drug” means a drug, including, but not limited to, a glucagon drug, glucose tablet or glucose gel, that does not contain insulin and is approved by the federal Food and Drug Administration to treat diabetes; and

(7) “Prescribing practitioner” has the same meaning as provided in section 20-571.

(b) Notwithstanding the provisions of section 38a-492a, each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for the treatment of all types of diabetes. Such coverage shall include, but need not be limited to, coverage for medically necessary:

(1) Laboratory and diagnostic testing and screening, including, but not limited to, hemoglobin A1c testing and retinopathy screening, for all types of diabetes;

(2) Insulin drugs (A) prescribed by a prescribing practitioner, or (B) prescribed and dispensed pursuant to subsection (d) of section 20-616 once during a policy year;

(3) Noninsulin drugs (A) prescribed by a prescribing practitioner, or (B) prescribed and dispensed pursuant to subsection (d) of section 20-616 once during a policy year if the noninsulin drug is a glucagon drug;

(4) Diabetes devices in accordance with the insured's diabetes treatment plan, including, but not limited to, diabetes devices prescribed and dispensed pursuant to subsection (d) of section 20-616 once during a policy year; and

(5) Diabetic ketoacidosis devices in accordance with the insured's diabetes treatment plan, including, but not limited to, diabetic ketoacidosis devices prescribed and dispensed pursuant to subsection (d) of section 20-616 once during a policy year.

(c) Notwithstanding the provisions of section 38a-492a, no policy described in subsection (b) of this section shall impose coinsurance, copayments, deductibles and other out-of-pocket expenses on an insured that exceed:

(1) Twenty-five dollars for each thirty-day supply of a medically necessary covered insulin drug (A) prescribed to the insured by a prescribing practitioner, or (B) prescribed and dispensed pursuant to subsection (d) of section 20-616 once during a policy year;

(2) Twenty-five dollars for each thirty-day supply of a medically necessary covered noninsulin drug (A) prescribed to the insured by a prescribing practitioner, or (B) prescribed and dispensed pursuant to subsection (d) of section 20-616 once during a policy year if such noninsulin drug is a glucagon drug;

(3) One hundred dollars for a thirty-day supply of all medically necessary covered diabetes devices and diabetic ketoacidosis devices for such insured that are in accordance with such insured's diabetes treatment plan, including, but not limited to, diabetes devices and diabetic ketoacidosis devices prescribed and dispensed pursuant to subsection (d) of section 20-616 once during a policy year.

(d) The provisions of subsection (c) of this section shall apply to a high deductible health plan to the maximum extent permitted by federal law, except if such plan is used to establish a medical savings account or an Archer MSA pursuant to Section 220 of the Internal Revenue Code of 1986, or any subsequent corresponding internal revenue code of the United States, as amended from time to time, or a health savings account pursuant to Section 223 of said Internal Revenue Code, as amended from time to time, the provisions of said subsection (c) shall apply to such plan to the maximum extent that (1) is permitted by federal law, and (2) does not disqualify such account for the deduction allowed under said Section 220 or 223, as applicable.

(P.A. 97-268, S. 4; P.A. 17-15, S. 51; July Sp. Sess. P.A. 20-4, S. 13.)

History: P.A. 17-15 deleted references to October 1, 1997; July Sp. Sess. P.A. 20-4 added new Subsec. (a) re definitions, redesignated existing Subsec. (a) as Subsec. (b), amended same by adding reference to Sec. 38a-492a, adding “amended or continued”, adding coverage for treatment of all types of diabetes, designating provisions re laboratory and diagnostic screening coverage as Subdiv. (1), adding Subdiv. (2) re insulin drug coverage, adding Subdiv. (3) re noninsulin drug coverage, adding Subdiv. (4) re diabetes device coverage and adding Subdiv. (5) re diabetic ketoacidosis device coverage, deleted former Subsec. (b), added Subsec. (c) re limitations on coinsurance, copayments, deductibles and other out-of-pocket expenses, added Subsec. (d) re high deductible health plans, and made technical and conforming changes throughout, effective January 1, 2022.

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

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

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

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

(P.A. 99-284, S. 43, 60; P.A. 17-15, S. 52; P.A. 19-98, S. 9; P.A. 21-196, S. 63.)

History: P.A. 99-284 effective January 1, 2000; P.A. 17-15 amended Subsec. (a) to delete reference to January 1, 2000; P.A. 19-98 amended Subsec. (b) by adding “or an advanced practice registered nurse”; P.A. 21-196 amended Subsec. (b) by adding reference to physician assistant.

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

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

(P.A. 99-284, S. 37, 60; P.A. 12-145, S. 56.)

History: P.A. 99-284 effective January 1, 2000; P.A. 12-145 added “amended” re policy and deleted “on or after January 1, 2000”, effective January 1, 2013.

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

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Sec. 38a-492g. Mandatory coverage for prostate cancer screening and treatment. Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for:

(1) Laboratory and diagnostic tests, including, but not limited to, prostate specific antigen (PSA) tests, to screen for prostate cancer for men who are symptomatic or whose biological father or brother has been diagnosed with prostate cancer, and for all men fifty years of age or older; and

(2) The treatment of prostate cancer, provided such treatment is medically necessary and in accordance with guidelines established by the National Comprehensive Cancer Network, the American Cancer Society or the American Society of Clinical Oncology.

(P.A. 99-284, S. 45, 60; P.A. 11-225, S. 1.)

History: P.A. 99-284 effective January 1, 2000; P.A. 11-225 inserted “amended” re policy, designated existing provision re screening coverage as Subdiv. (1), added Subdiv. (2) re treatment coverage, and made technical changes, effective January 1, 2012.

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

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

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

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

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

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Sec. 38a-492i. Mandatory coverage for pain management. (a) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (10), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide access to a pain management specialist and coverage for pain treatment ordered by such specialist that may include all means medically necessary to make a diagnosis and develop a treatment plan including the use of necessary medications and procedures.

(b) (1) No such policy that provides coverage for prescription drugs shall require an insured to use, prior to using a brand name prescription drug prescribed by a licensed physician for pain treatment, any alternative brand name prescription drugs or over-the-counter drugs.

(2) Such policy may require an insured to use, prior to using a brand name prescription drug prescribed by a licensed physician for pain treatment, a therapeutically equivalent generic drug.

(c) As used in this section, “pain” means a sensation in which a person experiences severe discomfort, distress or suffering due to provocation of sensory nerves, and “pain management specialist” means a physician who is credentialed by the American Academy of Pain Management or who is a board-certified anesthesiologist, physiatrist, neurologist, oncologist or radiation oncologist with additional training in pain management.

(P.A. 00-216, S. 18, 28; P.A. 11-169, S. 1; P.A. 12-197, S. 20.)

History: P.A. 00-216 effective January 1, 2001; P.A. 11-169 designated existing provisions as Subsecs. (a) and (c), added Subsec. (b) prohibiting insurers from requiring insured to use alternative brand name prescription drugs or over-the-counter drugs prior to using brand name prescription drug prescribed for pain treatment, and made technical changes, effective January 1, 2012; P.A. 12-197 amended Subsec. (c) by adding physiatrist to definition of “pain management specialist”, effective June 15, 2012.

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

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

(P.A. 00-63, S. 1; P.A. 10-5, S. 21; P.A. 11-204, S. 1.)

History: P.A. 10-5 made technical changes, effective January 1, 2011; P.A. 11-204 increased coverage cap from $1,000 to $2,500 annually, effective January 1, 2012.

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

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

(b) No such policy shall impose:

(1) A deductible for a procedure that a physician initially undertakes as a screening colonoscopy or a screening sigmoidoscopy; or

(2) A coinsurance, copayment, deductible or other out-of-pocket expense for any additional colonoscopy ordered in a policy year by a physician for an insured. The provisions of this subdivision shall not apply to a high deductible health plan as that term is used in subsection (f) of section 38a-493.

(P.A. 01-171, S. 20; P.A. 11-83, S. 1; P.A. 12-61, S. 1; 12-190, S. 1; P.A. 18-68, S. 12; July Sp. Sess. P.A. 20-4, S. 17.)

History: P.A. 11-83 designated existing provisions as Subsec. (a) and amended same to insert reference to American College of Radiology, add exception re Subsec. (b) and make a technical change, and added Subsec. (b) prohibiting out-of-pocket expense for additional colonoscopy ordered by physician in a policy year, effective January 1, 2012; P.A. 12-61 amended Subsec. (a) to delete “American College of Gastroenterology” and “American College of Radiology” re recommendations for colorectal cancer screening, effective January 1, 2013; P.A. 12-190 amended Subsec. (b) to redesignate existing provisions as Subdiv. (2) and make conforming changes therein, and add Subdiv. (1) re deductible for procedure initially undertaken as screening colonoscopy or screening sigmoidoscopy, effective January 1, 2013; P.A. 18-68 made a technical change in Subsec. (b)(2); July Sp. Sess. P.A. 20-4 amended Subsec. (b)(2) by substituting “high deductible health plan” for “high deductible plan”.

See Sec. 38a-472i for payment amount for professional services component of covered colonoscopy or endoscopy services.

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

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Sec. 38a-492l. Mandatory coverage for neuropsychological testing for children diagnosed with cancer. Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state on or after October 1, 2006, shall provide coverage without prior authorization for each child diagnosed with cancer on or after January 1, 2000, for neuropsychological testing ordered by a licensed physician, to assess the extent of any cognitive or developmental delays in such child due to chemotherapy or radiation treatment.

(P.A. 06-131, S. 2.)

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

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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 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, prescribing advanced practice registered nurse or prescribing optometrist 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; P.A. 16-39, S. 58; P.A. 17-15, S. 53.)

History: P.A. 09-136 effective January 1, 2010; P.A. 16-39 amended Subdiv. (2) by adding “, prescribing advanced practice registered nurse or prescribing optometrist”; P.A. 17-15 deleted reference to January 1, 2010.

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

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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.

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

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Sec. 38a-492o. Mandatory coverage for bone marrow testing. (a) Subject to the provisions of subsection (b) of this section, 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 shall provide coverage for expenses arising from human leukocyte antigen testing, also referred to as histocompatibility locus antigen testing, for A, B and DR antigens for utilization in bone marrow transplantation.

(b) No such policy shall impose a coinsurance, copayment, deductible or other out-of-pocket expense for such testing in excess of twenty per cent of the cost for such testing per year. The provisions of this subsection shall not apply to a high deductible health plan as that term is used in subsection (f) of section 38a-493.

(1) Require that such testing be performed in a facility (A) accredited by the American Society for Histocompatibility and Immunogenetics, or its successor, and (B) certified under the Clinical Laboratory Improvement Act of 1967, 42 USC Section 263a, as amended from time to time; and

(2) Limit coverage to individuals who, at the time of such testing, complete and sign an informed consent form that also authorizes the results of the test to be used for participation in the National Marrow Donor Program.

(d) Such policy may limit such coverage to a lifetime maximum benefit of one testing.

(P.A. 11-88, S. 1; P.A. 18-68, S. 13; July Sp. Sess. P.A. 20-4, S. 18.)

History: P.A. 11-88 effective January 1, 2012; P.A. 18-68 made a technical change in Subsec. (b); July Sp. Sess. P.A. 20-4 amended Subsec. (b) by substituting “high deductible health plan” for “high deductible plan”.

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

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Sec. 38a-492p. Mandatory coverage for medically monitored inpatient detoxification. Each insurance company, hospital service corporation, medical service corporation, health care center, fraternal benefit society or other entity that delivers, issues for delivery, renews, amends or continues in this state an individual health insurance policy providing coverage of the type specified in subdivision (1), (2), (4), (11) or (12) of section 38a-469 that provides coverage to an insured or enrollee who has been diagnosed with a substance use disorder, as described in section 17a-458, shall cover medically necessary, medically monitored inpatient detoxification services and medically necessary, medically managed intensive inpatient detoxification services provided to the insured or enrollee. For purposes of this section, “medically monitored inpatient detoxification” and “medically managed intensive inpatient detoxification” have the same meanings as described in the most recent edition of the American Society of Addiction Medicine Treatment Criteria for Addictive, Substance-Related and Co-Occurring Conditions.

(P.A. 17-131, S. 8.)

History: P.A. 17-131 effective January 1, 2018.

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Sec. 38a-492q. Mandatory coverage for essential health benefits. (a) For the purposes of this section, “essential health benefits” means health care services and benefits that fall within the following categories:

(1) Ambulatory patient services;

(2) Emergency services;

(3) Hospitalization;

(4) Maternity and newborn health care;

(5) Mental health and substance use disorder services, including, but not limited to, behavioral health treatment;

(6) Prescription drugs;

(7) Rehabilitative and habilitative services and devices;

(8) Laboratory services;

(9) Preventive and wellness services and chronic disease management; and

(10) Pediatric services, including, but not limited to, oral and vision care.

(c) No provision of the general statutes concerning a requirement of the Patient Protection and Affordable Care Act, P.L. 111-148, as amended from time to time, shall be construed to supersede any provision of this section that provides greater protection to an insured, except to the extent this section prevents the application of a requirement of the Affordable Care Act.

(d) The Insurance Commissioner may adopt regulations, in accordance with chapter 54, to carry out the purposes of this section, including, but not limited to, regulations specifying the health care services and benefits that fall within each category set forth in subsection (a) of this section.

(P.A. 18-10, S. 1.)

History: P.A. 18-10 effective January 1, 2019.

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

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Sec. 38a-492r. Mandatory coverage for certain immunizations and consultation with health care provider. (a) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state that provides coverage for prescription drugs shall provide (1) coverage for immunizations recommended by the American Academy of Pediatrics, American Academy of Family Physicians and the American College of Obstetricians and Gynecologists, and (2) with respect to immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the individual involved, coverage for such immunizations and at least a twenty-minute consultation between such individual and a health care provider authorized to administer such immunizations to such individual.

(b) No policy described in subsection (a) of this section shall impose a coinsurance, copayment, deductible or other out-of-pocket expense for the benefits and services required under said subsection. The provisions of this subsection shall apply to a high deductible health plan, as that term is used in subsection (f) of section 38a-493, to the maximum extent permitted by federal law, except if such plan is used to establish a medical savings account or an Archer MSA pursuant to Section 220 of the Internal Revenue Code of 1986, or any subsequent corresponding internal revenue code of the United States, as amended from time to time, or a health savings account pursuant to Section 223 of said Internal Revenue Code, as amended from time to time, the provisions of this subsection shall apply to such plan to the maximum extent that (1) is permitted by federal law, and (2) does not disqualify such account for the deduction allowed under said Section 220 or 223, as applicable. Nothing in this section shall preclude a policy that provides the coverage required under subsection (a) of this section and uses a provider network from imposing cost-sharing requirements for any benefit or service required under said subsection (a) that is delivered by an out-of-network provider.

(P.A. 18-10, S. 5; July Sp. Sess. P.A. 20-4, S. 19; P.A. 21-6, S. 10.)

History: P.A. 18-10 effective January 1, 2019; July Sp. Sess. P.A. 20-4 amended Subsec. (b) by substituting “high deductible health plan” for “high deductible plan”, adding references to medical savings accounts and Archer MSAs, and making technical and conforming changes; P.A. 21-6 amended Subsec. (a) by making technical changes and adding provisions to Subdiv. (2) re coverage for 20-minute consultation, effective January 1, 2022.

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

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Sec. 38a-492s. Mandatory coverage for certain preventive care and screenings for individuals who are twenty-one years of age or younger. (a) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for preventive care and screenings for individuals twenty-one years of age or younger in accordance with the most recent edition of the American Academy of Pediatrics' “Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents” or any subsequent corresponding publication.

(b) No such policy shall impose a coinsurance, copayment, deductible or other out-of-pocket expense for the benefits and services required under subsection (a) of this section. The provisions of this subsection shall apply to a high deductible health plan, as that term is used in subsection (f) of section 38a-493, to the maximum extent permitted by federal law, except if such plan is used to establish a medical savings account or an Archer MSA pursuant to Section 220 of the Internal Revenue Code of 1986, or any subsequent corresponding internal revenue code of the United States, as amended from time to time, or a health savings account pursuant to Section 223 of said Internal Revenue Code, as amended from time to time, the provisions of this subsection shall apply to such plan to the maximum extent that (1) is permitted by federal law, and (2) does not disqualify such account for the deduction allowed under said Section 220 or 223, as applicable. Nothing in this section shall preclude a policy that provides the coverage required under subsection (a) of this section and uses a provider network from imposing cost-sharing requirements for any benefit or service required under said subsection (a) that is delivered by an out-of-network provider.

(P.A. 18-10, S. 7; July Sp. Sess. P.A. 20-4, S. 20.)

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

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Sec. 38a-492t. Mandatory coverage for prosthetic devices. (a) As used in this section, “prosthetic device” means an artificial limb device to replace, in whole or in part, an arm or a leg, including a device that contains a microprocessor if such microprocessor-equipped device is determined by the insured's or enrollee's health care provider to be medically necessary. “Prosthetic device” does not include a device that is designed exclusively for athletic purposes.

(b) (1) Each individual health insurance policy providing coverage of the types specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for prosthetic devices that is at least equivalent to that provided under Medicare. Such coverage may be limited to a prosthetic device that is determined by the insured's or enrollee's health care provider to be the most appropriate to meet the medical needs of the insured or enrollee. Such prosthetic device shall not be considered durable medical equipment under such policy.

(2) Such policy shall provide coverage for the medically necessary repair or replacement of a prosthetic device, as determined by the insured's or enrollee's health care provider, unless such repair or replacement is necessitated by misuse or loss.

(3) No such policy shall impose a coinsurance, copayment, deductible or other out-of-pocket expense for a prosthetic device that is more restrictive than that imposed on substantially all other benefits provided under such policy, except that a high deductible health plan, as that term is used in subsection (f) of section 38a-493, shall not be subject to the deductible limits set forth in this subdivision or under Medicare pursuant to subdivision (1) of this subsection.

(c) An individual health insurance policy may require prior authorization for prosthetic devices, provided such authorization is required in the same manner and to the same extent as is required for other covered benefits under such policy.

(P.A. 18-69, S. 1; July Sp. Sess. P.A. 20-4, S. 21.)

History: P.A. 18-69 effective January 1, 2019; July Sp. Sess. P.A. 20-4 amended Subsec. (b)(3) by substituting “high deductible health plan” for “high deductible plan”.

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

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Sec. 38a-492u. Coverage for psychotropic drugs. Standards re availability. Notwithstanding any provision of the general statutes, no individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11), (12) and (16) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state on or after January 1, 2022, that provides coverage for outpatient prescription drugs shall: (1) Require a prescribing health care provider to prescribe a supply of a covered outpatient psychotropic drug that is larger than the supply of such drug that such provider deems clinically appropriate; or (2) if a prescribing health care provider deems a ninety-day supply of a covered outpatient psychotropic drug to be clinically inappropriate and prescribes less than a ninety-day supply of such drug, impose a coinsurance, copayment, deductible or other out-of-pocket expense for the prescribed supply of such drug in an amount that exceeds the amount of the coinsurance, copayment, deductible or other out-of-pocket expense for a ninety-day supply of such drug reduced pro rata in proportion to such prescribed supply of such drug.

(P.A. 21-125, S. 1.)

History: P.A. 21-125 effective January 1, 2022.

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

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Sec. 38a-493. (Formerly Sec. 38-174k). Mandatory coverage for home health care. Deductibles. Exception from deductible limits for medical savings accounts, Archer MSAs and health savings accounts. (a) 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 shall provide coverage providing reimbursement for home health care to residents in this state.

(b) For the purposes of this section and section 38a-494:

(1) “Hospital” means an institution that is primarily engaged in providing, by or under the supervision of physicians, to inpatients (A) diagnostic, surgical and therapeutic services for medical diagnosis, treatment and care of persons who have an injury, sickness or disability, or (B) medical rehabilitation services for the rehabilitation of persons who have an injury, sickness or disability. “Hospital” does not include a residential care home, nursing home, rest home or behavioral health facility, as defined in section 19a-490;

(2) “Home health care” means the continued care and treatment of a covered person who is under the care of a physician, a physician assistant or an advanced practice registered nurse but only if (A) continued hospitalization would otherwise have been required if home health care was not provided, except in the case of a covered person diagnosed by a physician, a physician assistant or an advanced practice registered nurse as terminally ill with a prognosis of six months or less to live, and (B) the plan covering the home health care is established and approved in writing by such physician, physician assistant or advanced practice registered nurse within seven days following termination of a hospital confinement as a resident inpatient for the same or a related condition for which the covered person was hospitalized, except that in the case of a covered person diagnosed by a physician, a physician assistant or an advanced practice registered nurse as terminally ill with a prognosis of six months or less to live, such plan may be so established and approved at any time irrespective of whether such covered person was so confined or, if such covered person was so confined, irrespective of such seven-day period, and (C) such home health care is commenced within seven days following discharge, except in the case of a covered person diagnosed by a physician, a physician assistant or an advanced practice registered nurse as terminally ill with a prognosis of six months or less to live;

(3) “Home health agency” means an agency or organization that meets each of the following requirements: (A) It is primarily engaged in and is federally certified as a home health agency and duly licensed, if such licensing is required, by the appropriate licensing authority, to provide nursing and other therapeutic services; (B) its policies are established by a professional group associated with such agency or organization, including at least one physician, physician assistant or advanced practice registered nurse and at least one registered nurse, to govern the services provided; (C) it provides for full-time supervision of such services by a physician, a physician assistant, an advanced practice registered nurse or a registered nurse; (D) it maintains a complete medical record on each patient; and (E) it has an administrator; and

(4) “Medical social services” means services rendered, under the direction of a physician, a physician assistant or an advanced practice registered nurse, by a qualified social worker holding a master's degree from an accredited school of social work, including, but not limited to, (A) assessment of the social, psychological and family problems related to or arising out of such covered person's illness and treatment, (B) appropriate action and utilization of community resources to assist in resolving such problems, and (C) participation in the development of the overall plan of treatment for such covered person.

(d) Home health care shall consist of, but shall not be limited to, the following: (1) Part-time or intermittent nursing care by a registered nurse or by a licensed practical nurse under the supervision of a registered nurse, if the services of a registered nurse are not available; (2) part-time or intermittent home health aide services, consisting primarily of patient care of a medical or therapeutic nature by other than a registered or licensed practical nurse; (3) physical, occupational or speech therapy; (4) medical supplies, drugs and medicines prescribed by a physician, a physician assistant or an advanced practice registered nurse and laboratory services to the extent such charges would have been covered under the policy or contract if the covered person had remained or had been confined in the hospital; and (5) medical social services provided to or for the benefit of a covered person diagnosed by a physician, a physician assistant or an advanced practice registered nurse as terminally ill with a prognosis of six months or less to live.

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

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

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

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

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

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

(P.A. 75-623, S. 1; P.A. 78-76, S. 1–3, 5; P.A. 84-375, S. 1, 3; P.A. 89-284; P.A. 90-243, S. 83; P.A. 96-19, S. 6; P.A. 97-112, S. 2; P.A. 03-78, S. 1; P.A. 04-174, S. 6; P.A. 11-19, S. 41, 43; P.A. 16-39, S. 59; P.A. 17-15, S. 54; 17-202, S. 88; July Sp. Sess. P.A. 20-4, S. 15; P.A. 21-196, S. 64; P.A. 22-58, S. 44; 22-92, S. 11.)

History: P.A. 78-76 specified applicability or inapplicability of provisions with respect to persons diagnosed as terminally ill with six months or less to live in Subsecs. (b), (d) and (e) and added “or had been” in Subsec. (i) preceding “hospitalized”; P.A. 84-375 amended Subsec. (g) to exclude major medical expense policies, as described in Subsec. (j), from the exemption in the subsection and added Subsec. (j), requiring that each major medical policy delivered, issued or renewed on or after October 1, 1984, provide coverage for home health care to residents who have exhausted their other policy or contract benefits; P.A. 89-284 amended Subsec. (b) to include a definition of “hospital” and amended Subsec. (j) to clarify that home health care shall be provided in accordance with this section under the major medical policies of insureds whose benefits are no longer provided under Medicare; P.A. 90-243 substituted references to “health insurance policies” for references to hospital and medical expense policies or contracts, added reference to health care centers and specified applicability solely to individual policies (Revisor's note: The reference to “or contract” at the end of Subsec. (h) was deleted editorially by the Revisors for conformity with the changes made by P.A. 90-243); Sec. 38-174k transferred to Sec. 38a-493 in 1991; P.A. 96-19 expanded reference in Subsec. (d) to prescriptions by physicians to include advanced practice registered nurses and physician assistants; P.A. 97-112 replaced “home for the aged” with “residential care home”; P.A. 03-78 amended Subsec. (f) to provide that a high deductible health plan shall not be subject to the deductible limits set forth in said Subsec., effective July 1, 2003; P.A. 04-174 amended Subsec. (f) to add references to “Archer MSA”, “health savings account” and Section 223 of the Internal Revenue Code re “high deductible health plans”, effective June 1, 2004; P.A. 11-19 inserted “amended or continued” and made technical changes in Subsecs. (a) and (j), effective January 1, 2012; P.A. 16-39 amended Subsecs. (b) to (e) by adding references to advanced practice registered nurse and made technical changes; P.A. 17-15 amended Subsec. (b) by adding reference to Sec. 38a-494, designating existing provisions defining “hospital” as Subdiv. (1), designating existing provisions defining “home health care” as Subdiv. (2), redesignating provisions of existing Subsec. (c) defining “home health agency” as Subsec. (b)(3) and redesignating provisions of existing Subsec. (d) defining “medical social services” as Subsec. (b)(4), and made technical and conforming changes; P.A. 17-202 amended Subsec. (b) by replacing “injured, disabled or sick persons” with “persons who have an injury, sickness or disability” in Subdivs. (1) and (2); July Sp. Sess. P.A. 20-4 amended Subsec. (f) by substituting “high deductible health plan” for “high deductible plan”; P.A. 21-196 amended Subsecs. (b), (d) and (e) by adding references to physician assistant and made a technical change in Subsec. (d); P.A. 22-58 amended Subsec. (b)(1) by replacing “alcohol or drug treatment facility” with “behavioral health facility”; P.A. 22-92 amended Subsec. (d)(4) by making a technical change, effective May 24, 2022.

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

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

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

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

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

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

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

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

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

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

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

(P.A. 79-289, S. 1, 2; P.A. 81-97; P.A. 86-49, S. 1, 3; 86-152; P.A. 87-181; 87-502; P.A. 88-124, S. 2; P.A. 90-243, S. 85; P.A. 92-111, S. 2, 4; P.A. 16-39, S. 60; P.A. 21-196, S. 65.)

History: P.A. 81-97 amended Subsec. (b), providing that a loss ratio of 75% be required for a group medicare supplement policy defined in the federal act; P.A. 86-49 excluded long-term care policies from the definition of “Medicare supplement policy”; P.A. 86-152 inserted new Subsec. (c) requiring that Medicare supplement policies provide coverage for home health aide services, relettering prior Subsecs. as necessary; P.A. 87-181 amended Subsec. (c) to make its provisions applicable to any Medicare supplement policy delivered, issued for delivery, continued or renewed on or after October 1, 1986; P.A. 87-502 inserted new Subsec. (d) defining what constitutes “hospitalization” for purposes of prescription drug coverage, relettering prior Subsecs. as necessary; P.A. 88-124 inserted new Subsec. (e) requiring that Medicare supplement policies provide coverage for mammography, relettering prior Subsecs. as necessary; P.A. 90-243 added references to health care centers, deleted provisions concerning group policies and substituted reference to health insurance policies for reference to accident and sickness policies; Sec. 38-174m transferred to Sec. 38a-495 in 1991; P.A. 92-111 amended Subsec. (g) to make the provisions of this section applicable to Medicare supplement policy regulations adopted pursuant to Sec. 38a-495a; P.A. 16-39 amended Subsecs. (c)(2) and (e) by adding references to advanced practice registered nurse and made a technical change; P.A. 21-196 amended Subsecs. (c) and (e) by adding references to physician assistant.

See Ch. 700d re fraternal benefit societies.

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

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

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

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

See Sec. 38a-800 re fraternal agents.

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

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

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

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

(4) “Commissioner” means the Insurance Commissioner.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(P.A. 92-111, S. 1, 4; P.A. 93-390, S. 6, 8; P.A. 97-57, S. 1–4; P.A. 10-5, S. 22; P.A. 15-118, S. 5; P.A. 17-15, S. 99, 102.)

History: P.A. 93-390 amended Subsec. (l) by deleting provision requiring outline of coverage to include automatic renewal premium increases in policyholders' premiums based on age, effective January 1, 1994; P.A. 97-57 amended Subsec. (a)(7) to delete reference to Section 1833 of the federal Social Security Act and replaced “demonstration project authorized pursuant to amendments to the federal Social Security Act” with “demonstration project specified in 42 USC Section 1395ss(g)(1), amended Subsec. (d) to make subsection subject to Subsec. (l)(4) of section and amended said Subsec. (l)(4) to delete reference to policies issued by reason of age, and to delete Subparas. (C) and (D), effective May 14, 1997; P.A. 10-5 made a technical change in Subsec. (f), effective May 5, 2010; P.A. 15-118 made technical changes in Subsec. (a)(5); P.A. 17-15 made technical changes in Subsec. (a)(7), and amended Subsec. (d) to delete “, including group conversion policies,”.

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

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

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

(b) In accordance with the regulations adopted pursuant to section 38a-495a, there shall be standardized Medicare supplement insurance policies or certificates as designated by the Centers for Medicare and Medicaid Services.

(P.A. 93-390, S. 1, 8; P.A. 05-20, S. 4; P.A. 11-19, S. 30; P.A. 17-15, S. 100.)

History: P.A. 93-390 effective January 1, 1994; P.A. 05-20 amended Subsec. (b) to substitute “July 1, 2005,” for “June 30, 1992,” and delete “ten” and substitute “A” to “L” for “A” to “J” re standardized policies or certificates, effective July 1, 2005; P.A. 11-19 amended Subsec. (b) to delete provision re Medicare supplement plans “A” to “L”, insert “Centers for Medicare and Medicaid Services” and make technical changes; P.A. 17-15 made technical changes in Subsec. (a).

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Sec. 38a-495c. Medicare supplement premium rates charged on a community rate basis. Age, gender, previous claim or medical history rating prohibited. Preexisting conditions. Coverage for the disabled and qualified Medicare beneficiaries. Exception. Regulations. (a) Each insurance company, fraternal benefit society, hospital service corporation, medical service corporation, health care center or other entity in this state that delivers, issues for delivery, continues or renews any Medicare supplement insurance policies or certificates shall base the premium rates charged on a community rate. Such rate shall not be based on age, gender, previous claims history or the medical condition of the person covered by such policy or certificate. Except as provided in subsection (c) of this section, coverage shall not be denied on the basis of age, gender, previous claim history or the medical condition of the person covered by such policy or certificate.

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

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

(d) Each insurance company, fraternal benefit society, hospital service corporation, medical service corporation, health care center or other entity in the state issuing Medicare supplement policies or certificates for plan “A”, “B”, “C” or “D”, or any combination thereof, to persons eligible for Medicare by reason of age, shall offer for sale the same such policies or certificates to persons eligible for Medicare by reason of disability, except no such company, society, corporation, center or other entity issuing any Medicare supplement policy or certificate for plan “C” shall be required to offer for sale such policy or certificate to any person who is a newly eligible Medicare beneficiary, as defined in 42 USC 1395ss(z)(2).

(e) To the extent permissible by federal law, each insurance company, fraternal benefit society, hospital service corporation, medical service corporation, health care center or other entity in the state issuing Medicare supplement policies or certificates for plan “A”, “B”, “C” or “D”, or any combination thereof, may deliver or issue for delivery such policy to a qualified Medicare beneficiary, as defined in 42 USC 1396d(p).

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

(g) The Insurance Commissioner may adopt regulations, in accordance with chapter 54, to implement this section.

(P.A. 93-390, S. 2, 8; Oct. Sp. Sess. P.A. 93-1, S. 1, 2; P.A. 98-32; P.A. 05-20, S. 5; P.A. 11-19, S. 31; P.A. 12-145, S. 14; P.A. 14-105, S. 1; June Sp. Sess. P.A. 21-2, S. 310.)

History: P.A. 93-390 effective January 1, 1994; Oct. Sp. Sess. P.A. 93-1 inserted new Subsec. (c) re exclusion of benefits for losses incurred within six months from the effective date of coverage based on a preexisting condition and relettered the remaining Subsecs. accordingly, effective January 1, 1994 (Revisor's note: In Subsecs. (d) and (e) the references to “other entities in the state” were changed editorially by the Revisors to “other entity in the state” for consistency with the language in Subsecs. (a), (b) and (c)); P.A. 98-32 amended Subsec. (d) to require those who issue Medicare supplements for plans “A”, “B” or “C”, or any combination thereof, on the basis of age to offer the same policy to persons eligible for Medicare by reason of disability, and deleted requirement that companies which issue Medicare supplements on basis of age must offer at least one such policy on basis of disability; P.A. 05-20 made technical changes throughout, amended Subsecs. (a) and (b) 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, and amended Subsec. (g) re regulations, effective July 1, 2005; P.A. 11-19 amended Subsecs. (a) and (b) to delete provisions re Medicare supplement plans “H” to “J”; P.A. 12-145 amended Subsec. (a) to delete “on or after January 1, 1994” and make a technical change, deleted former Subsec. (f) re application of section to policies or certificates issued on and after January 1, 1994, and redesignated existing Subsec. (g) as Subsec. (f), effective June 15, 2012; P.A. 14-105 added new Subsec. (e) re delivery or issuance for delivery of Medicare supplement policies to qualified Medicare beneficiaries and redesignated existing Subsecs. (e) and (f) as Subsecs. (f) and (g), effective July 1, 2014; June Sp. Sess. P.A. 21-2 amended Subsec. (d) by adding “or “D”” and exception re plan “C” and newly eligible Medicaid beneficiaries, amended Subsec. (e) by adding “or “D””, and made conforming changes, effective July 1, 2021.

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Sec. 38a-495d. Refund of prepaid premium for Medicare supplement policies. Each insurance company, fraternal benefit society, hospital service corporation, medical service corporation, health care center or other entity which delivers or issues for delivery, continues or renews in this state any Medicare supplement policy or certificate, as defined in sections 38a-495, 38a-495a and 38a-522, shall refund any prepaid premium made by a policyholder or certificate holder for coverage under such policy or certificate who subsequently elects to cancel his or her policy prior to the expiration of the coverage period.

(P.A. 07-48, S. 1.)

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

(1) “Occupational therapy” means services provided by a licensed occupational therapist in accordance with a plan of care established and approved in writing by a physician licensed in accordance with the provisions of chapter 370, a physician assistant licensed in accordance with the provisions of chapter 370 or an advanced practice registered nurse licensed in accordance with the provisions of chapter 378, who has certified that the prescribed care and treatment are not available from sources other than a licensed occupational therapist and which are provided in private practice or in a licensed health care facility. Such plan shall be reviewed and certified at least every two months by such physician, physician assistant or advanced practice registered nurse.

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

(3) “Rehabilitative agency” means an agency which provides an integrated multitreatment program designed to upgrade the function of persons with physical disabilities by bringing together, as a team, specialized personnel from various allied health fields.

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

(P.A. 82-148; P.A. 90-243, S. 86; P.A. 11-19, S. 45; P.A. 16-39, S. 61; P.A. 17-202, S. 89; P.A. 21-196, S. 66.)

History: P.A. 90-243 substituted reference to health insurance policies for reference to hospital and medical expense policies or contracts in Subsec. (b) and specified applicability solely to individual policies; Sec. 38-174q transferred to Sec. 38a-496 in 1991; P.A. 11-19 inserted “amended or continued” and made technical changes in Subsec. (b), effective January 1, 2012; P.A. 16-39 amended Subsec. (a)(1) by adding references to advanced practice registered nurse; P.A. 17-202 amended Subsec. (a)(3) by replacing “handicapped disabled individuals” with “persons with physical disabilities”; P.A. 21-196 amended Subsec. (a)(1) by adding references to physician assistant.

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

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Sec. 38a-497. (Formerly Sec. 38-174r). Termination of coverage of child, stepchild, or other dependent child in individual policies. Dental or vision coverage. (a) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state shall provide that coverage of a child, stepchild or other dependent child shall terminate not earlier than the policy anniversary date after the date on which the child, stepchild or other dependent child attains the age of twenty-six.

(b) Each individual health insurance policy described in subsection (a) of this section, and each individual health insurance policy providing coverage of the type specified in subdivision (16) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state, that includes or provides dental or vision coverage shall provide that dental or vision coverage of a child, stepchild or other dependent child shall terminate not earlier than the policy anniversary date after the date on which the child, stepchild or other dependent child attains the age of twenty-six.

(c) Each policy subject to this section shall cover a stepchild or other dependent child on the same basis as a biological child.

(d) Coverage for a child, stepchild or other dependent child under an insurance policy provided by the Comptroller for state employees or nonstate public employees pursuant to section 5-259 shall terminate not earlier than the end of the calendar year of the year in which the first of the following occurs: (1) The date such child, stepchild or other dependent child becomes covered under a group health plan through such dependent child's own employment; or (2) the date on which such dependent child attains the age of twenty-six.

(e) The provisions of subsection (d) of this section shall apply to insurance policies delivered, issued for delivery, amended, renewed or continued on or after July 1, 2022.

(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; P.A. 11-58, S. 37; P.A. 21-149, S. 1; P.A. 22-118, S. 170.)

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; P.A. 11-58 deleted requirements for termination of dependent coverage re marriage and state residency of a child, and made a technical change, effective July 2, 2011; P.A. 21-149 designated existing provisions re health insurance coverage for child as Subsec. (a) and amended same to add references to stepchild or other dependent child, delete provision re child becoming covered under group health plan through dependent's employment, and make technical and conforming changes, added Subsec. (b) re provisions re policy providing single ancillary dental or vision coverage, and designated existing provision requiring coverage of stepchild on same basis as biological child as Subsec. (c) and amended same to add reference to other dependent child and make technical changes, effective January 1, 2022; P.A. 22-118 added Subsec. (d) re insurance coverage for dependent child under Comptroller policy to terminate at end of calendar year of year dependent child becomes covered through own employment or attains age 26 and added Subsec. (e) re provisions of Subsec. (d) apply to policies delivered, amended, renewed or continued on or after July 1, 2022, effective July 1, 2022.

See Sec. 38a-508 for provisions re adopted children.

See Sec. 38a-512b for similar provisions re group policies.

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

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

(c) An insurer shall not deny enrollment of a child under the group health plan of the child's parent if: (1) The child was born out of wedlock, provided the father of the child has acknowledged paternity pursuant to section 46b-570 or has been adjudicated the father pursuant to section 46b-569; (2) the child is not claimed as a dependent on the federal income tax return of the parent; (3) the child does not reside with the parent or in the insurer's service area; or (4) if the child is receiving, or is eligible for benefits under a state medical assistance plan required by the Social Security Act.

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

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

(May Sp. Sess. P.A. 94-5, S. 4, 30; P.A. 95-305, S. 1, 6; June 18 Sp. Sess. P.A. 97-7, S. 15, 38; P.A. 98-27, S. 16; May 9 Sp. Sess. P.A. 02-7, S. 41; P.A. 07-247, S. 5; P.A. 14-122, S. 168.)

History: May Sp. Sess. P.A. 94-5 effective July 1, 1994; P.A. 95-305 inserted new Subsec. (a) defining “insurer”, relettering existing provisions as Subsec. (b) and added Subsecs. (c), (d) and (e) which provide requirements for the enrollment of a child in a parent's health plan, deleted former Subsec. (b) re adoption of regulations and made technical changes, effective July 1, 1995; June 18 Sp. Sess. P.A. 97-7 amended Subsec. (e) by adding provision re notification of new employer of noncustodial parent and notification of obligor and custodial parent re transfer of health insurance coverage and contest by noncustodial parent, effective July 1, 1997; P.A. 98-27 made a technical change in Subsec. (e); May 9 Sp. Sess. P.A. 02-7 amended Subsec. (a) by designating definition of “insurer” as Subdiv. (1), making a technical change therein and adding Subdiv. (2) defining “NMSN”, added Subsec. (b)(4) re compliance with NMSN, amended Subsec. (c) by changing “health plan” to “group health plan” and adding Subdiv. (4) re benefits under state medical assistance plan, amended Subsec. (d) by adding provisions re enrollment pursuant to and receipt of NMSN, enrollment dependent upon enrollment of participant and elimination of family health coverage by employer, and amended Subsec. (e) by adding provision re NMSN as application for health care coverage and reference to Sec. 46b-88; P.A. 07-247 amended Subsec. (e) by substituting “parent's” income for “obligor's” income and “each” parent for “the obligor and to the custodial” parent, by deleting reference to “noncustodial” parent, by substituting “A NMSN” for “The notice” and by adding “current” re support order; P.A. 14-122 made a technical change in Subsec. (a)(1).

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

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

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

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

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

(P.A. 83-325; P.A. 84-375, S. 2, 4; P.A. 90-243, S. 88; P.A. 94-239, S. 1; P.A. 02-124, S. 1; P.A. 12-145, S. 58; P.A. 15-118, S. 6.)

History: P.A. 84-375 amended Subsec. (a) to provide that on and after March 1, 1984, each hospital or medical expense insurance policy or hospital or medical service plan contract shall provide such coverage for ambulance services, that with more than one policy or contract, the hospital policy or contract shall be primary, that the benefits shall be subject to applicable policy or contract provisions, and $500 shall be the maximum mandatory benefit and added Subsec. (b), mandating direct payment to ambulance providers who meet certain requirements; P.A. 90-243 substituted reference to health insurance policies for reference to hospital and medical expense policies and contracts, deleted former Subsec. (b)(1) re group policies and designated former Subdivs. (2) and (3) as (1) and (2); Sec. 38-174t transferred to Sec. 38a-498 in 1991; P.A. 94-239 substituted “medically necessary” for “emergency” ambulance services and deleted the provision that the patient be admitted to the hospital; P.A. 02-124 amended Subsec. (a) to substitute “each” for “every”, rewrite provisions re policies renewed or amended in this state, substitute “October 1, 2002” for “March 1, 1984”, and substitute the maximum allowable rate established by the Department of Public Health for $500 re the maximum required coverage, inserted new Subsec. (b)(1) re direct payment for provider who complies with subsection, renumbered Subsecs. (b)(1) and (b)(2) as Subsecs. (b)(2) and (b)(3), respectively, and amended Subsec. (b)(3) to add “health care center or other entity”; P.A. 12-145 amended Subsec. (a) to add “or continued” re policy and delete “on or after October 1, 2002”, effective January 1, 2013; P.A. 15-118 made a technical change in Subsec. (b)(3).

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

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

(P.A. 96-67, S. 1.)

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

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

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Sec. 38a-498b. Mandatory coverage for mobile field hospital. Each individual health insurance policy providing coverage of the type specified in subdivisions (1) to (13), inclusive, of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide benefits for isolation care and emergency services provided by the state's mobile field hospital. Such benefits shall be subject to any policy provisions that apply to other services covered by such policy. The rates paid by individual health insurance policies pursuant to this section shall be equal to the rates paid under the Medicaid program, as determined by the Department of Social Services.

(P.A. 05-280, S. 64; P.A. 07-252, S. 70; P.A. 12-145, S. 49.)

History: P.A. 05-280 effective July 1, 2005; P.A. 07-252 substituted “mobile field hospital” for “critical access hospital” and made a technical change, effective July 12, 2007; P.A. 12-145 deleted “on or after July 1, 2005” and made a technical change, effective June 15, 2012.

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

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Sec. 38a-498c. Denial of coverage prohibited for health care services rendered to persons with an elevated blood alcohol content. No 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 shall deny coverage for health care services rendered to treat any injury sustained by any person when such injury is alleged to have occurred or occurs under circumstances in which (1) such person has an elevated blood alcohol content, or (2) such person has sustained such injury while under the influence of intoxicating liquor or any drug or both. For the purposes of this section, “elevated blood alcohol content” means a ratio of alcohol in the blood of such person that is eight-hundredths of one per cent or more of alcohol, by weight.

(P.A. 06-39, S. 1; P.A. 12-145, S. 51.)

History: P.A. 12-145 deleted “on or after October 1, 2006”, effective June 15, 2012.

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

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

(1) “Advanced practice registered nurse” means any advanced practice registered nurse licensed under the provisions of chapter 378;

(2) “Certified psychiatric-mental health advanced practice registered nurse” means any advanced practice registered nurse licensed under chapter 378 who is board certified as a psychiatric-mental health provider by the American Nurses Credentialing Center;

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

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

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

(P.A. 84-231; P.A. 90-243, S. 89; P.A. 95-74, S. 7, 9; P.A. 11-19, S. 47; P.A. 19-98, S. 10.)

History: P.A. 90-243 substituted references to “health insurance policy” for references to hospital and medical expense policies and contracts, applied provisions to health care centers and specified applicability solely to individual policies; Sec. 38-174v transferred to Sec. 38a-499 in 1991; P.A. 95-74 added physician assistants to those whose services must be included in coverage and defined “physician assistant”, effective July 1, 1995; P.A. 11-19 inserted “amended or continued” and made technical changes in Subsec. (b), effective January 1, 2012; P.A. 19-98 amended Subsec. (a) by replacing “certified nurse practitioner” with “advanced practice registered nurse” and replacing provisions defining “certified nurse practitioner” with provisions defining “advanced practice registered nurse” in Subdiv. (1), replacing “certified psychiatric-mental health clinical nurse specialist” with “certified psychiatric-mental health advanced practice registered nurse” and replacing provisions defining “certified psychiatric-mental health clinical nurse specialist” with provisions defining “certified psychiatric-mental health advanced practice registered nurse” in Subdiv. (2), amended Subsec. (b) by replacing references to certified nurse practitioners, clinical nurse specialists and certified registered nurses with references to advanced practice registered nurses, and made technical and conforming changes.

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

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Sec. 38a-499a. *(See end of section for amended version and effective date.) Coverage for telehealth services. (a) As used in this section, “telehealth” has the same meaning as provided in section 19a-906.

(b) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for medical advice, diagnosis, care or treatment provided through telehealth, to the extent coverage is provided for such advice, diagnosis, care or treatment when provided through in-person consultation between the insured and a health care provider. Such coverage shall be subject to the same terms and conditions applicable to all other benefits under such policy.

(c) No such policy shall: (1) Exclude a service for coverage solely because such service is provided only through telehealth and not through in-person consultation between the insured and a health care provider, provided telehealth is appropriate for the provision of such service; or (2) be required to reimburse a treating or consulting health care provider for the technical fees or technical costs for the provision of telehealth services.

(d) Nothing in this section shall prohibit or limit a health insurer, health care center, hospital service corporation, medical service corporation or other entity from conducting utilization review for telehealth services, provided such utilization review is conducted in the same manner and uses the same clinical review criteria as a utilization review for an in-person consultation for the same service.

(P.A. 15-88, S. 2; P.A. 17-15, S. 55.)

*Note: On and after July 1, 2024, this section, as amended by section 39 of public act 22-81, is to read as follows:

“Sec. 38a-499a. Coverage for telehealth services. (a) As used in this section, “telehealth” has the same meaning as provided in section 19a-906.

(b) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for medical advice, diagnosis, care or treatment provided through telehealth, to the extent coverage is provided for such advice, diagnosis, care or treatment when provided through in-person consultation between the insured and a health care provider licensed in the state. Such coverage shall be subject to the same terms and conditions applicable to all other benefits under such policy.

(c) No such policy shall: (1) Exclude a service for coverage solely because such service is provided only through telehealth and not through in-person consultation between the insured and a health care provider licensed in the state, provided telehealth is appropriate for the provision of such service; or (2) be required to reimburse a treating or consulting health care provider for the technical fees or technical costs for the provision of telehealth services.

(P.A. 15-88, S. 2; P.A. 17-15, S. 55; P.A. 22-81, S. 39.)

History: P.A. 15-88 effective January 1, 2016; P.A. 17-15 made a technical change in Subsec. (a); P.A. 22-81 amended Subsecs. (b) and (c) by adding “licensed in the state” re health care provider, effective July 1, 2024; (Revisor's note: In 2023, the words “of the general statutes” following a reference to Sec. 38-469 were deleted editorially by the Revisors for consistency with customary usage).

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

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

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

(P.A. 84-499, S. 1; P.A. 90-243, S. 90; P.A. 10-5, S. 23; P.A. 21-18, S. 1.)

History: P.A. 90-243 substituted reference to health insurance policies for hospital and medical expense policies and contracts, specified applicability to individual policies only and made technical grammatical change; Sec. 38-174w transferred to Sec. 38a-500 in 1991; (Revisor's note: In 1997 the phrase “type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) section 38a-469 delivered,” was changed editorially by the Revisors to “type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469 delivered,” to correct a clerical error); P.A. 10-5 deleted provision re first anniversary date of policy or contract and made technical changes in Subsec. (a), effective January 1, 2011; pursuant to P.A. 21-18, “workers' compensation commissioner” was changed editorially by the Revisors to “administrative law judge” in Subsec. (b), effective October 1, 2021.

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

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Sec. 38a-501. (Formerly Sec. 38-174x). Individual long-term care policies. Insurers authorized. Disclosures. Premium rate increases of twenty per cent or more. Disclosure of premium rate increase and minimum set of affordable benefit options. (a)(1) As used in this section and section 38a-475a, “long-term care policy” means any individual health insurance policy delivered or issued for delivery to any resident of this state on or after July 1, 1986, that is designed to provide, within the terms and conditions of the policy, benefits on an expense-incurred, indemnity or prepaid basis for necessary care or treatment of an injury, illness or loss of functional capacity provided by a certified or licensed health care provider in a setting other than an acute care hospital, for at least one year after an elimination period (A) not to exceed one hundred days of confinement, or (B) of over one hundred days but not to exceed two years of confinement, provided such period is covered by an irrevocable trust in an amount estimated to be sufficient to furnish coverage to the grantor of the trust for the duration of the elimination period. Such trust shall create an unconditional duty to pay the full amount held in trust exclusively to cover the costs of confinement during the elimination period, subject only to taxes and any trustee's charges allowed by law. Payment shall be made directly to the provider. The duty of the trustee may be enforced by the state, the grantor or any person acting on behalf of the grantor. A long-term care policy shall provide benefits for confinement in a nursing home or confinement in the insured's own home or both. Any additional benefits provided shall be related to long-term treatment of an injury, illness or loss of functional capacity. “Long-term care policy” does not include any such policy that is offered primarily to provide basic Medicare supplement coverage, basic medical-surgical expense coverage, hospital confinement indemnity coverage, major medical expense coverage, disability income protection coverage, accident only coverage, specified accident coverage or limited benefit health coverage.

(2) (A) Notwithstanding any provision of the general statutes, no insurance company, fraternal benefit society, hospital service corporation, medical service corporation or health care center may deliver, issue for delivery, renew, continue or amend any long-term care policy in this state on or after January 1, 2022, unless the insurance company, fraternal benefit society, hospital service corporation, medical service corporation or health care center is authorized or licensed to sell long-term care insurance and at least one other line of insurance in this state.

(B) No insurance company, fraternal benefit society, hospital service corporation, medical service corporation or health care center delivering, issuing for delivery, renewing, continuing or amending any long-term care policy in this state may refuse to accept, or refuse to make reimbursement pursuant to, a claim for benefits submitted by or prepared with the assistance of a managed residential community, as defined in section 19a-693, in accordance with subdivision (7) of subsection (a) of section 19a-694, solely because such claim for benefits was submitted by or prepared with the assistance of a managed residential community.

(C) Each insurance company, fraternal benefit society, hospital service corporation, medical service corporation or health care center delivering, issuing for delivery, renewing, continuing or amending any long-term care policy in this state shall, upon receipt of a written authorization executed by the insured, (i) disclose information to a managed residential community for the purpose of determining such insured's eligibility for an insurance benefit or payment, and (ii) provide a copy of the initial acceptance or declination of a claim for benefits to the managed residential community at the same time such acceptance or declination is made to the insured.

(b) (1) No insurance company, fraternal benefit society, hospital service corporation, medical service corporation or health care center may deliver or issue for delivery any long-term care policy that has a loss ratio of less than sixty per cent for any individual long-term care policy. An issuer shall not use or change premium rates for a long-term care policy unless the rates have been filed with and approved by the commissioner. Any rate filings or rate revisions shall demonstrate that anticipated claims in relation to premiums when combined with actual experience to date can be expected to comply with the loss ratio requirement of this section. A rate filing shall include the factors and methodology used to estimate irrevocable trust values if the policy includes an option for the elimination period specified in subdivision (1) of subsection (a) of this section.

(2) (A) Any insurance company, fraternal benefit society, hospital service corporation, medical service corporation or health care center that files a rate filing for an increase in premium rates for a long-term care policy that is for twenty per cent or more shall spread the increase over a period of not less than three years and not file a rate filing for an increase in premium rates for the long-term care policy during the period chosen. Such company, society, corporation or center shall use a periodic rate increase that is actuarially equivalent to a single rate increase and a current interest rate for the period chosen.

(B) Prior to implementing a premium rate increase, each such company, society, corporation or center shall:

(i) Notify its policyholders of such premium rate increase and make available to such policyholders the additional choice of reducing the policy benefits to reduce the premium rate or electing coverage that reflects the minimum set of affordable benefit options developed by the commissioner pursuant to section 38a-475a. Such notice shall include a description of such policy benefit reductions and minimum set of affordable benefit options. The premium rates for any benefit reductions shall be based on the new premium rate schedule;

(ii) Provide policyholders not less than thirty calendar days to elect a reduction in policy benefits or coverage that reflects the minimum set of affordable benefit options developed by the commissioner pursuant to section 38a-475a; and

(iii) Include a statement in such notice that if a policyholder fails to elect a reduction in policy benefits or coverage that reflects the minimum set of affordable benefit options developed by the commissioner pursuant to section 38a-475a by the end of the notice period and has not cancelled the policy, the policyholder will be deemed to have elected to retain the existing policy benefits.

(c) (1) No such company, society, corporation or center may deliver or issue for delivery any long-term care policy without providing, at the time of solicitation or application for purchase or sale of such coverage, full and fair written disclosure of the benefits and limitations of the policy.

(2) (A) The applicant shall sign an acknowledgment at the time of application for such policy that the company, society, corporation or center has provided the written disclosure required under this subsection to the applicant. If the method of application does not allow for such signature at the time of application, the applicant shall sign such acknowledgment not later than at the time of delivery of such policy.

(B) Except for a long-term care policy for which no applicable premium rate revision or rate schedule increases can be made or as otherwise provided in subdivision (3) of this subsection, such disclosure shall include:

(i) A statement that the policy may be subject to rate increases in the future;

(ii) An explanation of potential future premium rate revisions and the policyholder's option in the event of a premium rate revision;

(iii) The premium rate or rate schedule applicable to the applicant that will be in effect until such company, society, corporation or center files a request with the commissioner for a revision to such premium rate or rate schedule;

(iv) An explanation of how a premium rate or rate schedule revision will be applied that includes a description of when such rate or rate schedule revision will be effective; and

(v) Information regarding each premium rate increase, if any, over the past ten years on such policy form or similar policy forms for this state or any other state, that identifies, at a minimum, (I) the policy forms for which premium rates have been increased, (II) the calendar years when each such policy form was available for purchase, and (III) the amount or percentage of each increase. The percentage may be expressed as a percentage of the premium rate prior to the increase or as minimum and maximum percentages if the rate increase is variable by rating characteristics.

(C) The company, society, corporation or center may provide, in a fair manner, any additional explanatory information related to a premium rate or rate schedule revision.

(3) (A) Any such company, society, corporation or center may exclude from the disclosure required under subparagraph (B) of subdivision (2) of this subsection premium rate increases that only apply to blocks of business or long-term care policies acquired from a nonaffiliated company, society, corporation or center and that occurred prior to the acquisition.

(B) If an acquiring company, society, corporation or center files a request for a premium rate increase on or before January 1, 2015, or the end of a twenty-four-month period after the acquisition, whichever is later, for a block of policy forms or long-term care policies acquired from a nonaffiliated company, society, corporation or center, such acquiring company, society, corporation or center may exclude from the disclosure required under subparagraph (B) of subdivision (2) of this subsection such premium rate increase, except that the nonaffiliated company, society, corporation or center selling such block of policy forms or long-term care policies shall include such premium rate increase in such disclosure.

(C) If an acquiring company, society, corporation or center under subparagraph (B) of this subdivision files a subsequent request, even within the twenty-four-month period specified in said subparagraph, for a premium rate increase on the same block of policy forms or long-term care policies set forth in said subparagraph, the acquiring company, society, corporation or center shall include in the disclosure required under subparagraph (B) of subdivision (2) of this subsection such premium rate increase and any premium rate increase filed and approved pursuant to subparagraph (B) of this subdivision.

(4) If the offering for any long-term care policy includes an option for the elimination period specified in subdivision (1) of subsection (a) of this section, the application form for such policy and the face page of such policy shall contain a clear and conspicuous disclosure that the irrevocable trust may not be sufficient to cover all costs during the elimination period.

(d) No such company, society, corporation or center may deliver or issue for delivery any long-term care policy on or after July 1, 2008, without offering, at the time of solicitation or application for purchase or sale of such coverage, an option to purchase a policy that includes a nonforfeiture benefit. Such offer of a nonforfeiture benefit may be in the form of a rider attached to such policy. In the event the nonforfeiture benefit is declined, such company, society, corporation or center shall provide a contingent benefit upon lapse that shall be available for a specified period of time following a substantial increase in premium rates. Not later than July 1, 2008, the commissioner shall adopt regulations, in accordance with chapter 54, to implement the provisions of this subsection. Such regulations shall specify the type of nonforfeiture benefit that may be offered, the standards for such benefit, the period of time during which a contingent benefit upon lapse will be available and the substantial increase in premium rates that trigger a contingent benefit upon lapse in accordance with the Long-Term Care Insurance Model Regulation adopted by the National Association of Insurance Commissioners.

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

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

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

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

(P.A. 86-49, S. 2, 3; P.A. 89-236, S. 1, 3; P.A. 90-82; 90-243, S. 91; P.A. 91-276, S. 1; P.A. 94-39, S. 5; P.A. 07-28, S. 1; 07-226, S. 1; P.A. 10-127, S. 2; P.A. 12-145, S. 15; P.A. 13-134, S. 18, 19; P.A. 14-8, S. 1; 14-10, S. 1; P.A. 17-15, S. 56; P.A. 21-150, S. 3.)

History: P.A. 89-236 amended Subsec. (a) further defining “long-term care policy”, amended Subsec. (c) excluding policies issued to certain groups from disclosure requirement, amended Subsec. (d) detailing regulations to be adopted, added Subsec. (e) providing modification or suspension of requirements under certain conditions, added Subsec. (f) providing extension of preexisting condition exclusion period under certain conditions and added Subsec. (g) re appeal of commissioner's rulings; P.A. 90-82 allowed an insured the choice of a long-term care policy which provides benefits for confinement in the insured's own home or a policy which allows coverage for both nursing home and own home care where previously coverage was limited to nursing home care; P.A. 90-243 substituted reference to health insurance policies for reference to accident and sickness policies and deleted provisions concerning group coverage; Sec. 38-174x transferred to Sec. 38a-501 in 1991; P.A. 91-276 substituted 60% for 55% in Subsec. (b) re loss ratio for any individual long-term care policy; P.A. 94-39 amended Subsec. (b) by adding provision to require that issuer not use or change premium rates for a long-term policy without the filing and approval of the insurance commissioner and that such filing or revision comply with the loss ratio requirement for any individual long-term care policy; P.A. 07-28 inserted new Subsec. (d) requiring an offer of a nonforfeiture benefit in policies delivered or issued for delivery on or after July 1, 2008, provision of a contingent benefit upon lapse if the nonforfeiture benefit is declined and adoption of regulations to implement provisions of Subsec., and redesignated existing Subsecs. (d) to (g) as Subsec. (e) to (h), effective July 1, 2007; P.A. 07-226 amended Subsec. (a) to require an elimination period that is up to 100 days of confinement, or over 100 days but not exceeding two years of confinement if such period is covered by an irrevocable trust in an amount sufficient to cover grantor's confinement costs during such period, to require trust to create an unconditional duty to pay only confinement costs during such period, subject to taxes and trustee's fees, and to require trust to pay the health care provider directly, amended Subsec. (b) to require rate filing to include factors and methodology used to estimate trust values, and amended Subsec. (c) to require clear and conspicuous disclosure on application form and face page of policy that trust may be insufficient to cover all costs during the elimination period; P.A. 10-127 amended Subsec. (a) by designating existing provisions as Subdiv. (1) and making technical changes therein, and by adding Subdiv. (2) re claims for benefits submitted or prepared by and disclosure of information to managed residential communities, effective July 1, 2010; P.A. 12-145 made technical changes, effective June 15, 2012; P.A. 13-134 made technical changes in Subsecs. (b) and (e); P.A. 14-8 amended Subsec. (c) to designate existing provision re disclosure of policy benefits and limitations as Subdiv. (1) and amend same to replace “disclosure” with “written disclosure”, designate existing provision re disclosure of elimination period option as Subdiv. (4), and add Subdivs. (2) and (3) re acknowledgment, written disclosure and exclusions from disclosure, effective January 1, 2015; P.A. 14-10 amended Subsec. (b) to designate existing provisions as Subdiv. (1) and add Subdiv. (2) re requirement to spread premium rate increase of 20 per cent or more over 3 years and premium rate increase notice; P.A. 17-15 replaced “shall not include” with “does not include” re long-term care policy in Subsec. (a)(1), made technical changes in Subsec. (a)(2)(A), and replaced “health service corporation” with “hospital service corporation” in Subsec. (b)(2)(A); P.A. 21-150 amended Subsec. (a) by adding reference to Sec. 38a-475a in Subdiv. (1), adding new Subpara. (A) requiring insurers be authorized or licensed to sell at least 1 other line of insurance in this state in Subdiv. (2) and redesignating existing Subparas. (A) and (B) as Subparas. (B) and (C), amended Subsec. (b) by making a technical change in Subdiv. (1), adding provision prohibiting, for premium rate increase for 20 per cent or more, new rate filing for premium rate increase during period chosen in Subdiv. (2)(A), adding provisions re minimum set of affordable benefit options in Subdiv. (2)(B), and made technical changes in Subsecs. (c)(2)(B) and (d) to (g), effective January 1, 2022.

See Sec. 38a-528 for similar provisions re group policies.

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Sec. 38a-501a. Individual short-term care policies. Approval of rates and forms. Disclosures. Regulations. (a) As used in this section, “short-term care policy” means any individual health insurance policy delivered or issued for delivery to any resident of this state that is designed to provide, within the terms and conditions of the policy, benefits on an expense-incurred, indemnity or prepaid basis for necessary care or treatment of an injury, illness or loss of functional capacity provided by a certified or licensed health care provider in a setting other than an acute care hospital, for a period not exceeding three hundred days. “Short-term care policy” does not include any such policy that is offered primarily to provide basic Medicare supplement coverage, basic medical-surgical expense coverage, hospital confinement indemnity coverage, major medical expense coverage, disability income protection coverage, accident only coverage, specified accident coverage or limited benefit health coverage.

(b) (1) No short-term care policy shall be delivered or issued for delivery to any resident 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 Insurance Commissioner. The commissioner shall adopt regulations, in accordance with the provisions of chapter 54, to establish a procedure for reviewing such policies. The commissioner shall disapprove the use of such form at any time if the form does not conform to the requirements of law, or if the form contains a provision or provisions that are unfair or deceptive or that encourage misrepresentation of the policy. The commissioner shall notify, in writing, the insurer that 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.

(2) No rate filed under the provisions of subdivision (1) of this subsection shall be effective until it has been approved by the commissioner in accordance with regulations adopted pursuant to this subsection. The commissioner shall adopt regulations, in accordance with the provisions of chapter 54, to prescribe standards to ensure that such rates shall not be excessive, inadequate or unfairly discriminatory. The commissioner may disapprove such rate if it fails to comply with such standards.

(c) (1) No insurance company, fraternal benefit society, hospital service corporation, medical service corporation or health care center may deliver or issue for delivery any short-term care policy without providing, at the time of solicitation or application for purchase or sale of such coverage, full and fair written disclosure of the benefits and limitations of the policy.

(2) The applicant shall sign an acknowledgment at the time of application for such policy that the company, society, corporation or center has provided the written disclosure required under this subsection to the applicant. If the method of application does not allow for such signature at the time of application, the applicant shall sign such acknowledgment not later than at the time of delivery of such policy.

(3) Except for a short-term care policy for which no applicable premium rate revision or rate schedule increases can be made, such disclosure shall include:

(A) A statement in not less than twelve-point boldface type that the policy does not provide long-term care insurance coverage and is not a long-term care insurance policy or a Connecticut Partnership for Long-Term Care insurance policy;

(B) A statement that the policy may be subject to rate increases in the future;

(C) An explanation of potential future premium rate revisions and the policyholder's option in the event of a premium rate revision; and

(D) The premium rate or rate schedule applicable to the applicant that will be in effect until such company, society, corporation or center files a request with the commissioner for a revision to such premium rate or rate schedule.

(d) (1) No insurance company, fraternal benefit society, hospital service corporation, medical service corporation or health care center delivering, issuing for delivery, renewing, continuing or amending any short-term care policy in this state may refuse to accept, or refuse to make reimbursement pursuant to, a claim for benefits submitted by or prepared with the assistance of a managed residential community, as defined in section 19a-693, in accordance with subdivision (7) of subsection (a) of section 19a-694, solely because such claim for benefits was submitted by or prepared with the assistance of a managed residential community.

(2) Each insurance company, fraternal benefit society, hospital service corporation, medical service corporation or health care center delivering, issuing for delivery, renewing, continuing or amending any short-term care policy in this state shall, upon receipt of a written authorization executed by the insured, (A) disclose information to a managed residential community for the purpose of determining such insured's eligibility for an insurance benefit or payment, and (B) provide a copy of the initial acceptance or declination of a claim for benefits to the managed residential community at the same time such acceptance or declination is made to the insured.

(e) The commissioner shall adopt regulations, in accordance with the provisions of chapter 54, to implement the provisions of this section. Such regulations shall include, but need not be limited to, (1) the permissible loss ratio for a short-term care policy, if any, (2) the permissible exclusionary periods for coverage under a short-term care policy, if any, (3) the circumstances under which a short-term care policy will be renewable, and (4) the benefits payable under a short-term care policy in relation to other insurance coverage that provides benefits to the insured.

(P.A. 16-63, S. 2.)

See Sec. 38a-528a for similar provisions re group policies.

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

(P.A. 88-68; P.A. 90-243, S. 92; P.A. 04-169, S. 18; P.A. 16-167, S. 49.)

History: P.A. 90-243 substituted reference to health insurance policies for reference to hospital and medical expense policies and contracts and made technical grammatical change; Sec. 38-174ff transferred to Sec. 38a-502 in 1991; P.A. 04-169 changed the name of the Veterans' Home and Hospital to the Veterans' Home, effective June 1, 2004; P.A. 16-167 replaced “Veterans' Home” with “Healthcare Center in Rocky Hill maintained by the Department of Veterans Affairs”, effective July 1, 2016.

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

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(1) “Healthcare Common Procedure Coding System” or “HCPCS” means the billing codes used by Medicare and overseen by the federal Centers for Medicare and Medicaid Services that are based on the current procedural technology codes developed by the American Medical Association; and

(2) “Mammogram” means mammographic examination or breast tomosynthesis, including, but not limited to, a procedure with a HCPCS code of 77051, 77052, 77055, 77056, 77057, 77063, 77065, 77066, 77067, G0202, G0204, G0206 or G0279, or any subsequent corresponding code.

(b) (1) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (10), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide benefits for diagnostic and screening mammograms for insureds that are at least equal to the following minimum requirements:

(A) A baseline mammogram, which may be provided by breast tomosynthesis at the option of the insured covered under the policy, for an insured who is:

(i) Thirty-five to thirty-nine years of age, inclusive; or

(ii) Younger than thirty-five years of age if the insured is believed to be at increased risk for breast cancer due to:

(I) A family history of breast cancer;

(II) Positive genetic testing for the harmful variant of breast cancer gene one, breast cancer gene two or any other gene variant that materially increases the insured's risk for breast cancer;

(III) Prior treatment for a childhood cancer if the course of treatment for the childhood cancer included radiation therapy directed at the chest; or

(IV) Other indications as determined by the insured's physician, advanced practice registered nurse, physician assistant, certified nurse midwife or other medical provider; and

(B) Mammograms, which may be provided by breast tomosynthesis at the option of the insured covered under the policy, every year for an insured who is:

(i) Forty years of age or older; or

(ii) Younger than forty years of age if the insured is believed to be at increased risk for breast cancer due to:

(I) A family history, or prior personal history, of breast cancer;

(II) Positive genetic testing for the harmful variant of breast cancer gene one, breast cancer gene two or any other gene that materially increases the insured's risk for breast cancer;

(III) Prior treatment for a childhood cancer if the course of treatment for the childhood cancer included radiation therapy directed at the chest; or

(IV) Other indications as determined by the insured's physician, advanced practice registered nurse, physician assistant, certified nurse midwife or other medical provider.

(2) Such policy shall provide additional benefits for:

(A) Comprehensive diagnostic and screening ultrasounds of an entire breast or breasts if:

(i) 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

(ii) An insured is believed to be at increased risk for breast cancer due to:

(I) A family history or prior personal history of breast cancer;

(II) Positive genetic testing for the harmful variant of breast cancer gene one, breast cancer gene two or any other gene that materially increases the insured's risk for breast cancer;

(III) Prior treatment for a childhood cancer if the course of treatment for the childhood cancer included radiation therapy directed at the chest; or

(IV) Other indications as determined by the insured's physician, advanced practice registered nurse, physician assistant, certified nurse midwife or other medical provider;

(B) Diagnostic and screening magnetic resonance imaging of an entire breast or breasts:

(i) In accordance with guidelines established by the American Cancer Society for an insured who is thirty-five years of age or older; or

(ii) If an insured is younger than thirty-five years of age and believed to be at increased risk for breast cancer due to:

(I) A family history, or prior personal history, of breast cancer;

(II) Positive genetic testing for the harmful variant of breast cancer gene one, breast cancer gene two or any other gene that materially increases the insured's risk for breast cancer;

(III) Prior treatment for a childhood cancer if the course of treatment for the childhood cancer included radiation therapy directed at the chest; or

(IV) Other indications as determined by the insured's physician, advanced practice registered nurse, physician assistant, certified nurse midwife or other medical provider;

(D) Prophylactic mastectomies for an insured who is believed to be at increased risk for breast cancer due to positive genetic testing for the harmful variant of breast cancer gene one, breast cancer gene two or any other gene that materially increases the insured's risk for breast cancer; and

(E) Breast reconstructive surgery for an insured who has undergone:

(i) A prophylactic mastectomy; or

(ii) A mastectomy as part of the insured's course of treatment for breast cancer.

(c) Benefits under this section shall be subject to any policy provisions that apply to other services covered by such policy, except that no such policy shall impose a coinsurance, copayment, deductible or other out-of-pocket expense for such benefits. The provisions of this subsection shall apply to a high deductible health plan, as that term is used in subsection (f) of section 38a-493, to the maximum extent permitted by federal law, except if such plan is used to establish a medical savings account or an Archer MSA pursuant to Section 220 of the Internal Revenue Code of 1986 or any subsequent corresponding internal revenue code of the United States, as amended from time to time, or a health savings account pursuant to Section 223 of said Internal Revenue Code, as amended from time to time, the provisions of this subsection shall apply to such plan to the maximum extent that (1) is permitted by federal law, and (2) does not disqualify such account for the deduction allowed under said Section 220 or 223, as applicable.

(d) Each mammography report provided to an insured 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, physician assistant's or advanced practice registered nurse's office and you should contact your physician, physician assistant or advanced practice registered nurse 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; P.A. 11-67, S. 1; 11-171, S. 1; P.A. 12-150, S. 1; P.A. 14-97, S. 1; P.A. 16-82, S. 1; P.A. 18-159, S. 1; P.A. 19-98, S. 11; 19-117, S. 209; July Sp. Sess. P.A. 20-4, S. 22; P.A. 21-196, S. 67; P.A. 22-90, 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; P.A. 11-67 amended Subsec. (a) to add mandatory coverage for magnetic resonance imaging if a mammogram demonstrates heterogeneous or dense breast tissue or if a woman is believed to be at increased risk for breast cancer due to family or prior personal history, and to make technical changes, effective January 1, 2012; P.A. 11-171 amended Subsec. (a) to add mandatory coverage for magnetic resonance imaging in accordance with guidelines established by the American Cancer Society or the American College of Radiology, and to make technical changes, effective January 1, 2012; P.A. 12-150 amended Subsec. (a)(2) to delete “and magnetic resonance imaging” in Subpara. (A) and add “of an entire breast or breasts” and delete reference to American College of Radiology in Subpara. (B), amended Subsec. (c) to delete “On and after October 1, 2009”, and made technical changes, effective June 15, 2012; P.A. 14-97 amended Subsec. (b) to add provision limiting copayment for breast ultrasound screening to maximum of $20, effective January 1, 2015; P.A. 16-82 amended Subsec. (a)(1) by adding “, which may be provided by breast tomosynthesis at the option of the woman covered under the policy,” in Subparas. (A) and (B), effective January 1, 2017; P.A. 18-159 added new Subsec. (a) defining “Healthcare Common Procedure Coding System” and “Mammogram”, redesignated existing Subsecs. (a) to (c) as Subsecs. (b) to (d), and made conforming changes, effective January 1, 2019; P.A. 19-98 amended Subsec. (d) to add references to advanced practice registered nurse; P.A. 19-117 amended Subsec. (b)(2)(A) by designating existing provisions re heterogeneous or dense breast tissue as Subpara. (A)(i), designating existing provisions re women believed to be at increased risk for breast cancer as Subpara. (A)(ii) and adding Subpara. (A)(iii) re screening recommended by woman's treating physician, and amended Subsec. (c) by deleting provision re maximum of $20 for ultrasound screening and adding provisions prohibiting coinsurances, copayments, deductibles, out-of-pocket expenses and concerning high deductible plans, effective January 1, 2020; July Sp. Sess. P.A. 20-4 amended Subsec. (c) by substituting “high deductible health plan” for “high deductible plan”; P.A. 21-196 amended Subsecs. (b)(2)(A) and (d) by adding references to physician assistant; P.A. 22-90 amended Subsec. (b) by adding “diagnostic and screening” re coverage for mammograms, replaced “woman” with “insured”, added Subpara. (A)(ii) and corresponding subclauses (I) through (IV) re coverage for baseline mammogram for insured under 35 years of age if at increased risk for breast cancer due to family history, positive genetic testing for harmful variants, prior treatment for a childhood cancer involving radiation directed at the chest or other indications determined by insured's provider, added Subpara. (B)(ii) and corresponding subclauses (I) through (IV) re coverage for annual mammogram for insured younger than 40 years of age if at increased risk for breast cancer due to family history, positive genetic testing for harmful variants, prior treatment for a childhood cancer involving radiation directed at the chest or other indications determined by insured's provider, amended Subsec. (b)(2) by replacing “ultrasound screening” with “diagnostic and screening ultrasounds” in Subpara. (A), adding in clause (ii)(II)that at increased risk includes positive genetic testing for harmful variants, adding in clause (ii)(III) that at increased risk includes prior treatment for a childhood cancer involving radiation directed at the chest, adding in clause (ii)(IV) reference to certified nurse midwife or other medical provider and deleting former clause (iii) of Subpara. (2)(A) re screening recommendation by physician, replacing “magnetic” with “diagnostic and screening magnetic” in Subpara. (B), adding in coverage requirements in clauses (i) through (iv) of Subpara. (B) and corresponding subclauses re insured who is at least 35 years of age and believed to be at increased risk for breast cancer due to family history, positive genetic testing for harmful variants, prior treatment for a childhood cancer involving radiation directed at the chest or other indications determined by insured's provider, added Subpara. (C) in Subsec. (b)(2) re coverage for breast biopsies, amended Subpara. (D) in Subsec. (b)(2) re coverage for prophylactic mastectomies for insured at increased risk due to positive genetic testing of harmful variants, amended Subpara. (E) in Subsec. (b)(2) re coverage for breast reconstructive surgery for insured who has undergone prophylactic mastectomy or mastectomy as part of breast cancer treatment, in Subsec. (d) replaced “a patient” with “an insured” and made technical changes in Subsec. (b), effective January 1, 2023.

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

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Sec. 38a-503a. Mandatory coverage for breast cancer survivors. Section 38a-503 is repealed, effective January 1, 2020.

(P.A. 96-177, S. 4; P.A. 17-15, S. 57; P.A. 19-134, S. 2.)

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

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

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

(P.A. 95-199, S. 1; P.A. 96-227, S. 14; P.A. 01-171, S. 18; P.A. 10-32, S. 120; P.A. 11-19, S. 49; P.A. 14-122, S. 50; P.A. 19-125, S. 10.)

History: P.A. 96-227 amended Subsec. (a) to include Subdiv. (12) in its citation to Sec. 38a-469; P.A. 01-171 amended Subsec. (b) to provide that “such obstetric and gynecologic services include, but are not limited to, pap smear tests”; P.A. 10-32 made a technical change in Subsec. (b), effective May 10, 2010; P.A. 11-19 inserted “or continuing” and made technical changes in Subsec. (a), effective January 1, 2012; P.A. 14-122 made a technical change in Subsec. (b); P.A. 19-125 amended Subsec. (a) to redefine “carrier”, effective January 1, 2020.

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

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Sec. 38a-503c. Mandatory coverage for maternity care. Interhospital transfer of newborn infant and mother. (a) As used in this section, “carrier” means each insurer, health care center, hospital service corporation, medical service corporation or other entity delivering, issuing for delivery, renewing, amending or continuing any individual health insurance policy in this state providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469.

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

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

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

(e) No individual health insurance carrier subject to this section shall require prior authorization for the interhospital transfer of (1) a newborn infant experiencing a life-threatening emergency or condition, or (2) the hospitalized mother of such newborn infant to accompany her newborn infant.

(P.A. 96-177, S. 1, 6; P.A. 11-19, S. 51; P.A. 15-118, S. 52; P.A. 16-162, S. 1.)

History: P.A. 96-177 effective May 24, 1996; P.A. 11-19 inserted “or continuing” and made technical changes in Subsec. (a), effective January 1, 2012; P.A. 15-118 deleted former Subsec. (e) re policyholder notice requirement; P.A. 16-162 added Subsec. (e) re interhospital transfer of newborn infant and mother, effective January 1, 2017.

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

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

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

(P.A. 97-198, S. 1, 5; P.A. 11-19, S. 8.)

History: P.A. 97-198 effective July 1, 1997; P.A. 11-19 made a technical change in Subsec. (a).

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

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Sec. 38a-503e. Mandatory coverage for contraceptives and sterilization. (a) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for the following benefits and services:

(1) All contraceptive drugs, including, but not limited to, all over-the-counter contraceptive drugs, approved by the federal Food and Drug Administration. Such policy may require an insured to use, prior to using a contraceptive drug prescribed to the insured, a contraceptive drug that the federal Food and Drug Administration has designated as therapeutically equivalent to the contraceptive drug prescribed to the insured, unless otherwise determined by the insured's prescribing health care provider.

(2) All contraceptive devices and products, excluding all over-the-counter contraceptive devices and products, approved by the federal Food and Drug Administration. Such policy may require an insured to use, prior to using a contraceptive device or product prescribed to the insured, a contraceptive device or product that the federal Food and Drug Administration has designated as therapeutically equivalent to the contraceptive device or product prescribed to the insured, unless otherwise determined by the insured's prescribing health care provider.

(3) If a contraceptive drug, device or product described in subdivision (1) or (2) of this subsection is prescribed by a licensed physician, physician assistant or advanced practice registered nurse, a twelve-month supply of such contraceptive drug, device or product dispensed at one time or at multiple times, unless the insured or the insured's prescribing health care provider requests less than a twelve-month supply of such contraceptive drug, device or product. No insured shall be entitled to receive a twelve-month supply of a contraceptive drug, device or product pursuant to this subdivision more than once during any policy year.

(4) All sterilization methods approved by the federal Food and Drug Administration for women.

(5) Routine follow-up care concerning contraceptive drugs, devices and products approved by the federal Food and Drug Administration.

(6) Counseling in (A) contraceptive drugs, devices and products approved by the federal Food and Drug Administration, and (B) the proper use of contraceptive drugs, devices and products approved by the federal Food and Drug Administration.

(b) No policy described in subsection (a) of this section shall impose a coinsurance, copayment, deductible or other out-of-pocket expense for the benefits and services required under said subsection (a), except that any such policy that uses a provider network may require cost-sharing when such benefits and services are rendered by an out-of-network provider. The cost-sharing limits imposed under this subsection shall apply to a high deductible health plan, as that term is used in subsection (f) of section 38a-493, to the maximum extent permitted by federal law, except if such plan is used to establish a medical savings account or an Archer MSA pursuant to Section 220 of the Internal Revenue Code of 1986 or any subsequent corresponding internal revenue code of the United States, as amended from time to time, or a health savings account pursuant to Section 223 of said Internal Revenue Code, as amended from time to time, the provisions of this subsection shall apply to such plan to the maximum extent that (1) is permitted by federal law, and (2) does not disqualify such account for the deduction allowed under said Section 220 or 223, as applicable.

(c) (1) Notwithstanding any other provision of this section, any insurance company, hospital service corporation, medical service corporation, or health care center may issue to a religious employer an individual health insurance policy that excludes coverage for benefits and services required under subsection (a) of this section that are contrary to the religious employer's bona fide religious tenets.

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

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

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

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

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

(P.A. 99-79, S. 1; P.A. 11-19, S. 53; P.A. 15-118, S. 7, 8; P.A. 18-10, S. 11; July Sp. Sess. P.A. 20-4, S. 23.)

History: P.A. 11-19 inserted “amended” and made a technical change in Subsec. (a), effective January 1, 2012; P.A. 15-118 made technical changes in Subsecs. (b) and (e); P.A. 18-10 amended Subsec. (a) by replacing provision prohibiting coverage exclusions with provisions re coverage of benefits and services and adding Subdivs. (1) to (6) re said benefits and services, added new Subsec. (b) re cost-sharing, redesignated existing Subsecs. (b) to (f) as Subsecs. (c) to (g), and made conforming changes, effective January 1, 2019; July Sp. Sess. P.A. 20-4 amended Subsec. (b) by substituting “high deductible health plan” for “high deductible plan”, adding reference to medical savings account and Archer MSA, and making technical and conforming changes.

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

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Sec. 38a-503f. Mandatory coverage for certain health benefits and services for women, infants, children and adolescents. (a)(1) Except as provided in subdivision (2) of this subsection, each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for the following benefits and services:

(A) Domestic and interpersonal violence screening and counseling for any woman;

(B) Tobacco use intervention and cessation counseling for any woman who consumes tobacco;

(D) Breast cancer chemoprevention counseling for any woman who is 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 such woman's physician or advanced practice registered nurse;

(E) Breast cancer risk assessment, genetic testing and counseling;

(F) Chlamydia infection screening for any sexually-active woman;

(G) Cervical and vaginal cancer screening for any sexually-active woman;

(H) Gonorrhea screening for any sexually-active woman;

(I) Human immunodeficiency virus screening for any sexually-active woman;

(J) Human papillomavirus screening for any woman with normal cytology results who is thirty years of age or older;

(K) Sexually transmitted infections counseling for any sexually-active woman;

(L) Anemia screening for any pregnant woman and any woman who is likely to become pregnant;

(M) Folic acid supplements for any pregnant woman and any woman who is likely to become pregnant;

(N) Hepatitis B screening for any pregnant woman;

(O) Rhesus incompatibility screening for any pregnant woman and follow-up rhesus incompatibility testing for any pregnant woman who is at increased risk for rhesus incompatibility;

(P) Syphilis screening for any pregnant woman and any woman who is at increased risk for syphilis;

(Q) Urinary tract and other infection screening for any pregnant woman;

(R) Breastfeeding support and counseling for any pregnant or breastfeeding woman;

(S) Breastfeeding supplies, including, but not limited to, a breast pump for any breastfeeding woman;

(T) Gestational diabetes screening for any woman who is twenty-four to twenty-eight weeks pregnant and any woman who is at increased risk for gestational diabetes;

(U) Osteoporosis screening for any woman who is sixty years of age or older;

(V) Such additional evidence-based items or services not described in subparagraphs (A) to (U), inclusive, of this subdivision that receive a rating of “A” or “B” in any recommendations of the United States Preventive Services Task Force effective after January 1, 2018; and

(W) With respect to infants, children and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the United States Health Resources and Services Administration, as effective on January 1, 2018, and such additional preventive care and screenings provided for in any comprehensive guidelines supported by said administration and effective after January 1, 2018.

(2) No policy described in subdivision (1) of this subsection shall be required to provide coverage for any benefit or service described in subparagraphs (A) to (U), inclusive, of said subdivision unless such benefit or service is an evidence-based item or service that had a rating of “A” or “B” in the recommendations of the United States Preventive Services Task Force as such recommendations were in effect on January 1, 2018.

(b) No policy described in subsection (a) of this section shall impose a coinsurance, copayment, deductible or other out-of-pocket expense for the benefits and services required under said subsection. The provisions of this subsection shall apply to a high deductible health plan, as that term is used in subsection (f) of section 38a-493, to the maximum extent permitted by federal law, except if such plan is used to establish a medical savings account or an Archer MSA pursuant to Section 220 of the Internal Revenue Code of 1986 or any subsequent corresponding internal revenue code of the United States, as amended from time to time, or a health savings account pursuant to Section 223 of said Internal Revenue Code, as amended from time to time, the provisions of this subsection shall apply to such plan to the maximum extent that (1) is permitted by federal law, and (2) does not disqualify such account for the deduction allowed under said Section 220 or 223, as applicable. Nothing in this section shall preclude a policy that provides the coverage required under subsection (a) of this section and uses a provider network from imposing cost-sharing requirements for any benefit or service required under said subsection (a) that is delivered by an out-of-network provider.

(P.A. 18-10, S. 3; July Sp. Sess. P.A. 20-4, S. 24.)

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

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Sec. 38a-503g. Mandatory coverage for ovarian cancer screening and monitoring. (a) For purposes of this section:

(1) “At risk for ovarian cancer” means:

(A) Having a family history:

(i) With one or more first degree blood relatives, including a parent, sibling or child, or one or more second degree blood relatives, including an aunt, uncle, grandparent, grandchild, niece, nephew, half-brother or half-sister with ovarian or breast cancer; or

(ii) Of nonpolyposis colorectal cancer; or

(B) Positive genetic testing for the harmful variant of breast cancer gene one, breast cancer gene two or any other gene variant that materially increases the insured's risk for breast cancer, ovarian cancer or any other gynecological cancers.

(2) “Surveillance tests for ovarian cancer” means annual screening using:

(A) CA-125 serum tumor marker testing;

(B) Transvaginal ultrasound;

(D) Other ovarian cancer screening tests currently being evaluated by the United States Food and Drug Administration or by the National Cancer Institute.

(b) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (10), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide benefits for:

(1) Genetic testing for insureds having a family history of breast or ovarian cancer;

(2) Routine screening procedures for ovarian cancer and the office or facility visit for such screening, including surveillance tests for ovarian cancer for insureds who are at risk for ovarian cancer, when ordered or provided by a physician in accordance with the standard practice of medicine;

(3) CA-125 monitoring of ovarian cancer subsequent to treatment; and

(4) Genetic testing of the breast cancer gene one, breast cancer gene two, any other gene variant that materially increases the insured's risk for breast and ovarian cancer or any other gynecological cancer to detect an increased risk for breast and ovarian cancer when recommended by a health care provider in accordance with the United States Preventive Services Task Force recommendations for testing.

(c) Benefits under this section shall be subject to any policy provisions that apply to other services covered by such policy, except that no such policy shall impose a coinsurance, copayment, deductible or other out-of-pocket expense for such benefits. The provisions of this subsection shall apply to a high deductible health plan, as that term is used in subsection (f) of section 38a-520, to the maximum extent permitted by federal law, except if such plan is used to establish a medical savings account or an Archer MSA pursuant to Section 220 of the Internal Revenue Code of 1986 or any subsequent corresponding internal revenue code of the United States, as amended from time to time, or a health savings account pursuant to Section 223 of said Internal Revenue Code, as amended from time to time, the provisions of this subsection shall apply to such plan to the maximum extent that (1) is permitted by federal law, and (2) does not disqualify such account for the deduction allowed under said Section 220 or 223, as applicable.

(P.A. 22-90, S. 3.)

History: P.A. 22-90 effective January 1, 2023.

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

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

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

(d) (1) Each policy of the type specified in subsection (a) of this section that provides coverage for intravenously administered and orally administered anticancer medications used to kill or slow the growth of cancerous cells that are prescribed by a prescribing practitioner, as defined in section 20-571, shall provide coverage for orally administered anticancer medications on a basis that is no less favorable than intravenously administered anticancer medications.

(2) No insurance company, hospital service corporation, medical service corporation, health care center or fraternal benefit society that delivers, issues for delivery, renews, amends or continues in this state a policy of the type specified in subsection (a) of this section shall reclassify such anticancer medications or increase the coinsurance, copayment, deductible or other out-of-pocket expense imposed under such policy for such medications to achieve compliance with this subsection.

(P.A. 79-327, S. 2; P.A. 86-54; P.A. 87-40; 87-275, S. 2; P.A. 90-243, S. 94; P.A. 97-198, S. 3, 5; P.A. 98-27, S. 17; P.A. 04-34, S. 1; P.A. 10-5, S. 24; 10-63, S. 1; P.A. 11-19, S. 10.)

History: P.A. 86-54 clarified the section by limiting its applicability to individual and group medical expense insurance policies and contract plans, rather than to all individual and group health insurance policies and contract plans; P.A. 87-40 amended Subsec. (c) to increase the minimum coverage requirement for prosthesis from $200 to $300; P.A. 87-275 amended Subsec. (c) to provide that the yearly benefit for prosthesis shall be at least $300 for each breast surgically removed due to tumors; P.A. 90-243 deleted former Subsec. (a) re group coverages, relettered the remaining Subsecs., added references to health care centers, substituted references to health insurance policies for references to medical expense policies or contracts; Sec. 38-262i transferred to Sec. 38a-504 in 1991; P.A. 97-198 added exception in Subsec. (b) and added new Subsec. (c) re breast reconstruction after mastectomy, effective July 1, 1997; P.A. 98-27 amended Subsec. (a) to delete reference to Sec. 38a-469(6); P.A. 04-34 amended Subsec. (a) to substitute “Each” for “Any” and require coverage for a wig if prescribed for a patient who suffers hair loss as a result of chemotherapy and amended Subsec. (b) to require a yearly benefit of $350 for a wig; P.A. 10-5 made technical changes in Subsecs. (a) and (b), effective January 1, 2011; P.A. 10-63 made technical changes in Subsecs. (a) and (b), and added Subsec. (d) re orally administered anticancer medications, effective January 1, 2011; P.A. 11-19 made technical changes in Subsec. (d).

See Ch. 700d re fraternal benefit societies.

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

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

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

See Sec. 38a-800 re fraternal agents.

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Sec. 38a-504a. Coverage for routine patient care costs associated with certain clinical trials. Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for the routine patient care costs, as defined in section 38a-504d, associated with clinical trials, in accordance with sections 38a-504b to 38a-504g, inclusive. As used in this section and sections 38a-504b to 38a-504g, inclusive, “clinical trial” means an organized, systematic, scientific study of therapies, tests or other clinical interventions for purposes of treatment or palliation or therapeutic intervention for the prevention of cancer or disabling or life-threatening chronic diseases in human beings.

(P.A. 01-171, S. 8, 25; P.A. 11-19, S. 57; 11-172, S. 1.)

History: P.A. 01-171 effective January 1, 2002; P.A. 11-19 inserted “amended or continued”, redefined “cancer clinical trial” and made a technical change, effective January 1, 2012; P.A. 11-172 inserted “amended or continued”, replaced reference to cancer clinical trials with reference to clinical trials, changed defined term from “cancer clinical trial” to “clinical trial” and redefined same, and made technical changes, effective January 1, 2012.

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

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Sec. 38a-504b. Clinical trial criteria. A clinical trial for the prevention of cancer shall be eligible for coverage only if it involves a therapeutic intervention, is a phase III clinical trial approved by one of the entities identified in this section, and is conducted at multiple institutions. In order to be eligible for coverage of routine patient care costs, as defined in section 38a-504d, a clinical trial shall be (1) conducted under the auspices of an independent peer-reviewed protocol that has been reviewed and approved by: (A) One of the National Institutes of Health; (B) a National Cancer Institute affiliated cooperative group; (C) the federal Food and Drug Administration as part of an investigational new drug or device application or exemption; or (D) the federal Department of Defense or Veterans Affairs; or (2) qualified to receive Medicare coverage of its routine costs under the Medicare Clinical Trial Policy established under the September 19, 2000, Medicare National Coverage Determination, as amended from time to time. Nothing in sections 38a-504a to 38a-504g, inclusive, shall be construed to require coverage for any single institution clinical trial conducted solely under the approval of the institutional review board of an institution, or any trial that is no longer approved by an entity identified in subparagraph (A), (B), (C) or (D) of subdivision (1) of this section.

(P.A. 01-171, S. 9, 25; P.A. 11-19, S. 58; 11-172, S. 2.)

History: P.A. 01-171 effective January 1, 2002; P.A. 11-19 added provision limiting eligibility of clinical trial for the prevention of cancer, effective January 1, 2012; P.A. 11-172 replaced references to cancer clinical trial with references to clinical trial, designated existing clinical trial criteria as Subdiv. (1) and amended same to insert “application or” re investigational new drug or device, added Subdiv. (2) re Medicare qualification, and made technical changes, effective January 1, 2012.

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

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Sec. 38a-504c. Evidence and information re eligibility for clinical trial. No coverage required for otherwise reimbursable costs. In order to be eligible for coverage of routine patient care costs, as defined in section 38a-504d, the insurer, health care center or plan administrator may require that the person or entity seeking coverage for the clinical trial provide: (1) Evidence satisfactory to the insurer, health care center or plan administrator that the insured person receiving coverage meets all of the patient selection criteria for the clinical trial, including credible evidence in the form of clinical or preclinical data showing that the clinical trial is likely to have a benefit for the insured person that is commensurate with the risks of participation in the clinical trial to treat the person's condition; (2) evidence that the appropriate informed consent has been received from the insured person; (3) copies of any medical records, protocols, test results or other clinical information used by the physician or institution seeking to enroll the insured person in the clinical trial; (4) a summary of the anticipated routine patient care costs in excess of the costs for standard treatment; (5) information from the physician or institution seeking to enroll the insured person in the clinical trial regarding those items, including any routine patient care costs, that are eligible for reimbursement by an entity other than the insurer or health care center, including the entity sponsoring the clinical trial; and (6) any additional information that may be reasonably required for the review of a request for coverage of the clinical trial. The health plan or insurer shall request any additional information about a clinical trial not later than five business days after receiving a request for coverage from an insured person or a physician seeking to enroll an insured person in a clinical trial. Nothing in sections 38a-504a to 38a-504g, inclusive, shall be construed to require the insurer or health care center to provide coverage for routine patient care costs that are eligible for reimbursement by an entity other than the insurer, including the entity sponsoring the clinical trial.

(P.A. 01-171, S. 10, 25; P.A. 11-19, S. 59; 11-172, S. 3.)

History: P.A. 01-171 effective January 1, 2002; P.A. 11-19 made technical changes, effective January 1, 2012; P.A. 11-172 replaced references to cancer clinical trial with references to clinical trial and made technical changes, effective January 1, 2012.

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

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Sec. 38a-504d. Clinical trials: Routine patient care costs. (a) For purposes of sections 38a-504a to 38a-504g, inclusive, “routine patient care costs” means: (1) Medically necessary health care services that are incurred as a result of the treatment being provided to the insured person for purposes of the clinical trial that would otherwise be covered if such services were not rendered pursuant to a clinical trial. Such services shall include those rendered by a physician, diagnostic or laboratory tests, hospitalization or other services provided to the insured person during the course of treatment in the clinical trial for a condition, or one of its complications, that is consistent with the usual and customary standard of care and would be covered if the insured person were not enrolled in a clinical trial. Such hospitalization shall include treatment at an out-of-network facility if such treatment is not available in-network and not eligible for reimbursement by the sponsors of such clinical trial, and (2) costs incurred for drugs provided to the insured person, in accordance with section 38a-492b, provided such drugs have been approved for sale by the federal Food and Drug Administration.

(b) Routine patient care costs shall be subject to the terms, conditions, restrictions, exclusions and limitations of the contract or certificate of insurance between the insured person and the insurer or health plan, including limitations on out-of-network care, except that treatment at an out-of-network hospital as provided in subdivision (1) of subsection (a) of this section shall be made available by the out-of-network hospital and the insurer or health care center at no greater cost to the insured person than if such treatment was available in-network. The insurer or health care center may require that any routine tests or services required under the clinical trial protocol be performed by providers or institutions under contract with the insurer or health care center.

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

(P.A. 01-171, S. 11, 25; P.A. 07-67, S. 1; P.A. 11-19, S. 60; 11-172, S. 4.)

History: P.A. 01-171 effective January 1, 2002; P.A. 07-67 amended Subsec. (a)(1) to require that hospitalization include treatment at an out-of-network facility if treatment is not available in-network and not eligible for reimbursement by sponsors of clinical trial, and amended Subsec. (b) to require out-of-network hospitalization to be made available at the in-network level of benefits under the policy or contract, effective May 30, 2007; P.A. 11-19 amended Subsec. (a) to replace “38a-518b” with “38a-492b” in Subdiv. (2) and make technical changes, effective January 1, 2012; P.A. 11-172 replaced references to cancer clinical trial with references to clinical trial, replaced “38a-518b” with “38a-492b” in Subsec. (a)(2) and made technical changes, effective January 1, 2012.

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

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

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

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

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

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

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

(P.A. 01-171, S. 12, 25; P.A. 11-172, S. 5.)

History: P.A. 01-171 effective January 1, 2002; P.A. 11-172 replaced references to cancer clinical trial with references to clinical trial and, in Subsecs. (c), (d) and (f), changed “may not” to “shall not”, effective January 1, 2012.

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

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Sec. 38a-504f. Clinical trials: Standardized forms. Time frame for coverage determinations. Appeals. Regulations. (a)(1) For purposes of cancer clinical trials, the Insurance Department, in cooperation with the Connecticut Oncology Association, the American Cancer Society, the Connecticut Association of Health Plans and Anthem Blue Cross of Connecticut, shall develop a standardized form that all providers, hospitals and institutions shall submit to the insurer or health care center when seeking to enroll an insured person in a cancer clinical trial. An insurer or health care center shall not substitute any other approval request form for the form developed by the department, except that any insurer or health care center that has entered into an agreement to provide coverage for cancer clinical trials approved pursuant to section 38a-504g may use the form or process established by such agreement.

(2) For purposes of clinical trials other than cancer clinical trials, the Insurance Department, in cooperation with at least one state nonprofit research or advocacy organization concerned with the subject of the clinical trial, at least one national nonprofit research or advocacy organization concerned with the subject of the clinical trial, the Connecticut Association of Health Plans and Anthem Blue Cross of Connecticut, shall develop a standardized form that all providers, hospitals and institutions shall submit to the insurer or health care center when seeking to enroll an insured person in a clinical trial. An insurer or health care center shall not substitute any other approval request form for the form developed by the department, except that any insurer or health care center that has entered into an agreement to provide coverage for clinical trials approved pursuant to section 38a-504g may use the form or process established by such agreement.

(b) Any insurer or health care center that receives the department form from a provider, hospital or institution seeking coverage for the routine patient care costs of an insured person in a clinical trial shall approve or deny coverage for such services not later than five business days after receiving such request and any other reasonable supporting materials requested by the insurer or health plan pursuant to section 38a-504c, except that an insurer or health care center that utilizes independent experts to review such requests shall respond not later than ten business days after receiving such request and supporting materials.

(c) The insured, or the provider with the insured's written consent, may appeal any denial of coverage for medical necessity to an external, independent review pursuant to section 38a-591g. Such external review shall be conducted by a properly qualified review agent whom the department has determined does not have a conflict of interest regarding the clinical trial.

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

(P.A. 01-171, S. 13, 25; P.A. 11-19, S. 61; 11-58, S. 83; 11-172, S. 6.)

History: P.A. 01-171 effective January 1, 2002; P.A. 11-19 made technical changes in Subsec. (b), effective January 1, 2012; P.A. 11-58 replaced reference to Sec. 38a-478n with “section 38a-591g” in Subsec. (c), effective July 1, 2011; P.A. 11-172 amended Subsec. (a) by designating existing provisions as Subdiv. (1) and amending same to change “may not” to “shall not” and by adding Subdiv. (2) re standardized form for clinical trials other than cancer clinical trials, amended Subsec. (b) by replacing references to cancer clinical trial with references to clinical trial, deleting provision re time period for approval or denial of coverage for phase III clinical trials for prevention of cancer and by making technical changes, and amended Subsec. (c) by replacing reference to cancer clinical trial with reference to clinical trial, effective January 1, 2012.

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

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

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

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

(P.A. 01-171, S. 14, 25; P.A. 11-172, S. 7; P.A. 12-145, S. 16.)

History: P.A. 01-171 effective January 1, 2002; P.A. 11-172 replaced references to cancer clinical trials with references to clinical trials in Subsec. (a), effective January 1, 2012; P.A. 12-145 replaced references to Sec. 38a-504g with references to Sec. 38a-504f, effective June 15, 2012.

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

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

(1) The commissioner shall adopt regulations, in accordance with the provisions of chapter 54, to establish specific standards for policy provisions used in individual health insurance policies, that shall be in addition to and in accordance with sections 38a-80, 38a-321 to 38a-324, inclusive, 38a-326, 38a-329, 38a-334 to 38a-336a, inclusive, 38a-338 to 38a-358, inclusive, 38a-470 to 38a-472, inclusive, 38a-475, 38a-480 to 38a-503, inclusive, 38a-507, 38a-514, 38a-519, 38a-523, 38a-531, 38a-577 to 38a-590, inclusive, and 38a-802 to 38a-810, inclusive, and other applicable laws of this state that may cover the terms of renewability, initial and subsequent conditions of eligibility, nonduplication of coverage provisions, coverage of dependents, termination of insurance, probationary periods, limitations, exceptions, reductions, elimination periods, requirements for replacements, recurrent conditions, preexisting conditions, and the definition of the terms hospital, accident, sickness, injury, physician, accidental means, total disability, permanent disability, partial disability, nervous disorders, guaranteed renewable and noncancellable.

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

(3) The commissioner shall adopt regulations, in accordance with the provisions of chapter 54, to establish minimum standards for benefits under each of the following categories of coverage in individual policies: Basic hospital expense coverage, basic medical-surgical expense coverage, hospital confinement indemnity coverage, major medical expense coverage, disability income protection coverage, accident only coverage, specified accident coverage and specified disease coverage.

(4) Nothing in this section shall preclude the issuance of any policy that combines two or more of the categories of coverage enumerated in subdivision (3) of this section, except that specified accident coverage shall not be combined with any other category of coverage. The commissioner shall prescribe the method of identification of policies based upon coverage provided.

(5) No policy shall be delivered or issued for delivery in this state that does not meet the prescribed minimum standards for the categories of coverage listed in subdivision (3) of this section, provided nothing in this section shall preclude the delivery or issuance of any policy that does not meet such prescribed minimum standards of coverage so long as such policy is clearly identified as not meeting such prescribed standards.

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

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

(P.A. 75-616, S. 8, 12; P.A. 76-399, S. 4, 5; P.A. 90-200, S. 2; 90-243, S. 155; P.A. 93-297, S. 22, 23, 29; P.A. 08-181, S. 5; P.A. 15-247, S. 10; P.A. 17-15, S. 58.)

History: P.A. 76-399 clarified prohibition of specific disease policies in Subsec. (c) to specify “riders and benefits” and “whether issued on a group or individual basis”; P.A. 90-200 amended Subsec. (c) to allow the issuance of specified disease policies for accelerated benefits of life insurance policies provided the commissioner adopts regulations re minimum standards for issuance; P.A. 90-243 substituted “health insurance policies” for “accident and sickness contracts” and deleted the reference to “contracts”; Sec. 38-378 transferred to Sec. 38a-505 in 1991; P.A. 93-297 added references to Sec. 38a-336a in Subsecs. (a) and (g), effective January 1, 1994, and applicable to acts or omissions occurring on or after said date; P.A. 08-181 amended Subsec. (c) by deleting prohibition on sale of specified disease policies, riders and benefits and adding specified disease coverage to list of individual policies for which commissioner is directed to adopt regulations, effective June 12, 2008; P.A. 15-247 redesignated existing Subsecs. (a) to (f) and (h) as Subdivs. (1) to (7), respectively, amended redesignated Subdiv. (1) by adding reference to Ch. 54 and deleting reference to group conversion policies, amended redesignated Subdiv. (3) by deleting reference to conversion policies, deleted former Subsec. (g) re use of simplified application form, and made technical and conforming changes, effective July 10, 2015; P.A. 17-15 made technical changes in Subdivs. (2), (3) and (5).

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

(1949 Rev., S. 6189; 1951, S. 2843d; P.A. 90-243, S. 95; P.A. 08-178, S. 16; P.A. 15-118, S. 9.)

History: P.A. 90-243 applied provisions to hospital or medical service corporations, health care centers, and fraternal benefit societies and substituted “foreign” for “nonresident” and “alien” for “foreign” insurance companies; Section 38-173 transferred to Sec. 38a-506 in 1991; P.A. 08-178 increased maximum fine from $500 to $10,000 per offense; P.A. 15-118 made a technical change.

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Sec. 38a-507. Coverage for services performed by chiropractors. Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6) and (11) of section 38a-469, delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for services rendered by a chiropractor licensed under chapter 372 to the same extent coverage is provided for services rendered by a physician, if such chiropractic services (1) treat a condition covered under such policy, and (2) are within those services a chiropractor is licensed to perform.

(P.A. 89-112; P.A. 90-243, S. 176; P.A. 11-19, S. 55; P.A. 17-15, S. 97.)

History: P.A. 90-243 substituted “health insurance policy” for “group hospital”, “medical expense insurance policy” and “individual or group hospital or medical service plan” and deleted references to “contract”; P.A. 11-19 inserted “amended or continued” and made technical changes, effective January 1, 2012; P.A. 17-15 added “providing coverage of the type specified in subdivisions (1), (2), (4), (6) and (11) of section 38a-469,”.

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

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

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

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

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

(P.A. 91-97, S. 1; P.A. 02-96, S. 1; P.A. 03-70, S. 1; P.A. 15-118, S. 10.)

History: P.A. 02-96 amended Subsec. (a) to substitute “each” for “every” and “amended, renewed or continued in this state” for “amended or renewed in this state on or after October 1, 1991,” and added Subsec. (d) re coverage and prohibited provisions; P.A. 03-70 amended Subsec. (d) to add exception re health underwriting if required premium or subscription fee and completed application materials are not provided before expiration of thirty-one-day period; P.A. 15-118 made technical changes in Subsecs. (c) and (d).

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

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Sec. 38a-509. Mandatory coverage for infertility diagnosis and treatment. Limitations. (a) Subject to the limitations set forth in subsection (b) of this section and except as provided in subsection (c) of this section, 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, 2018, shall provide coverage for the medically necessary expenses of the diagnosis and treatment of infertility, including, but not limited to, ovulation induction, intrauterine insemination, in-vitro fertilization, uterine embryo lavage, embryo transfer, gamete intra-fallopian transfer, zygote intra-fallopian transfer and low tubal ovum transfer. For purposes of this section, “infertility” means the condition of an individual who is unable to conceive or produce conception or sustain a successful pregnancy during a one-year period or such treatment is medically necessary.

(b) Such policy may:

(1) Limit such coverage to an individual until the date of such individual's fortieth birthday;

(2) Limit such coverage for ovulation induction to a lifetime maximum benefit of four cycles;

(3) Limit such coverage for intrauterine insemination to a lifetime maximum benefit of three cycles;

(4) Limit lifetime benefits to a maximum of two cycles, with not more than two embryo implantations per cycle, for in-vitro fertilization, gamete intra-fallopian transfer, zygote intra-fallopian transfer or low tubal ovum transfer, provided each such fertilization or transfer shall be credited toward such maximum as one cycle;

(5) Limit coverage for in-vitro fertilization, gamete intra-fallopian transfer, zygote intra-fallopian transfer and low tubal ovum transfer to those individuals who have been unable to conceive or produce conception or sustain a successful pregnancy through less expensive and medically viable infertility treatment or procedures covered under such policy. Nothing in this subdivision shall be construed to deny the coverage required by this section to any individual who foregoes a particular infertility treatment or procedure if the individual's physician determines that such treatment or procedure is likely to be unsuccessful;

(6) Require that covered infertility treatment or procedures be performed at facilities that conform to the standards and guidelines developed by the American Society of Reproductive Medicine or the Society of Reproductive Endocrinology and Infertility;

(7) Limit coverage to individuals who have maintained coverage under such policy for at least twelve months; and

(8) Require disclosure by the individual seeking such coverage to such individual's existing health insurance carrier of any previous infertility treatment or procedures for which such individual received coverage under a different health insurance policy. Such disclosure shall be made on a form and in the manner prescribed by the Insurance Commissioner.

(c) (1) Any insurance company, hospital service corporation, medical service corporation or health care center may issue to a religious employer an individual health insurance policy that excludes coverage for methods of diagnosis and treatment of infertility that are contrary to the religious employer's bona fide religious tenets.

(2) Upon the written request of an individual who states in writing that methods of diagnosis and treatment of infertility are contrary to such individual's religious or moral beliefs, any insurance company, hospital service corporation, medical service corporation or health care center may issue to or on behalf of the individual a policy or rider thereto that excludes coverage for such methods.

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

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

(P.A. 05-196, S. 1; P.A. 15-118, S. 11; P.A. 17-55, S. 1.)

History: P.A. 15-118 made technical changes in Subsec. (c); P.A. 17-55 amended Subsec. (a) by replacing “October 1, 2005,” with “January 1, 2018,” replacing “a presumably healthy individual” with “an individual”, and adding “or such treatment is medically necessary”, effective January 1, 2018.

See Sec. 38a-536 for similar provisions re group policies.

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Sec. 38a-510. Prescription drug coverage. Mail order pharmacies. Step therapy use. (a) No insurance company, hospital service corporation, medical service corporation, health care center or other entity delivering, issuing for delivery, renewing, amending or continuing an individual health insurance policy or contract that provides coverage for prescription drugs may:

(1) Require any person covered under such policy or contract to obtain prescription drugs from a mail order pharmacy as a condition of obtaining benefits for such drugs; or

(2) Require, if such insurance company, hospital service corporation, medical service corporation, health care center or other entity uses step therapy for such drugs, the use of step therapy for (A) any prescribed drug for longer than sixty days, or (B) a prescribed drug for cancer treatment for an insured who has been diagnosed with stage IV metastatic cancer provided such prescribed drug is in compliance with approved federal Food and Drug Administration indications.

(3) At the expiration of the time period specified in subparagraph (A) of subdivision (2) of this subsection or for a prescribed drug described in subparagraph (B) of subdivision (2) of this subsection, an insured's treating health care provider may deem such step therapy drug regimen clinically ineffective for the insured, at which time the insurance company, hospital service corporation, medical service corporation, health care center or other entity shall authorize dispensation of and coverage for the drug prescribed by the insured's treating health care provider, provided such drug is a covered drug under such policy or contract. If such provider does not deem such step therapy drug regimen clinically ineffective or has not requested an override pursuant to subdivision (1) of subsection (b) of this section, such drug regimen may be continued. For purposes of this section, “step therapy” means a protocol or program that establishes the specific sequence in which prescription drugs for a specified medical condition are to be prescribed.

(b) (1) Notwithstanding the sixty-day period set forth in subdivision (2) of subsection (a) of this section, each insurance company, hospital service corporation, medical service corporation, health care center or other entity that uses step therapy for such prescription drugs shall establish and disclose to its health care providers a process by which an insured's treating health care provider may request at any time an override of the use of any step therapy drug regimen. Any such override process shall be convenient to use by health care providers and an override request shall be expeditiously granted when an insured's treating health care provider demonstrates that the drug regimen required under step therapy (A) has been ineffective in the past for treatment of the insured's medical condition, (B) is expected to be ineffective based on the known relevant physical or mental characteristics of the insured and the known characteristics of the drug regimen, (C) will cause or will likely cause an adverse reaction by or physical harm to the insured, or (D) is not in the best interest of the insured, based on medical necessity.

(2) Upon the granting of an override request, the insurance company, hospital service corporation, medical service corporation, health care center or other entity shall authorize dispensation of and coverage for the drug prescribed by the insured's treating health care provider, provided such drug is a covered drug under such policy or contract.

(c) Nothing in this section shall (1) preclude an insured or an insured's treating health care provider from requesting a review under sections 38a-591c to 38a-591g, inclusive, or (2) affect the provisions of section 38a-492i.

(P.A. 05-233, S. 1; P.A. 14-118, S. 1; P.A. 17-228, S. 1.)

History: P.A. 05-233 effective July 1, 2005; P.A. 14-118 amended Subsec. (a) to designate existing provision re mail order pharmacy as Subdiv. (1) and add Subdiv. (2) re step therapy, deleted former Subsec. (b) re application of section, added new Subsec. (b) re step therapy override, added Subsec. (c) re effect of section on Secs. 38a-591c to 38a-591g and 38a-492i, and made technical and conforming changes, effective January 1, 2015; P.A. 17-228 amended Subsec. (a) to designate existing provisions re prescribed drug for longer than 60 days as Subpara. (A), and add Subpara. (B) re prescribed drug for cancer treatment in Subdiv. (2), designate existing provisions re deeming step therapy drug regimen clinically ineffective as Subdiv. (3) and amended same to add reference to Subdiv. (2), and make technical changes, effective January 1, 2018.

See Sec. 38a-544 for similar provisions re group policies.

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Sec. 38a-510a. Prescription drug coverage. Synchronized refills. No individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11), (12) and (16) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state that provides coverage for prescription drugs shall deny coverage for the refill of any drug prescribed for the treatment of a chronic illness that is made in accordance with a plan among the insured, a practitioner and a pharmacist to synchronize the refilling of multiple prescriptions for the insured.

(P.A. 13-131, S. 1.)

History: P.A. 13-131 effective January 1, 2014.

See Sec. 38a-544a for similar provisions re group policies.

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Sec. 38a-510b. Prescription drug coverage. Prior authorization for naloxone hydrochloride or similar drug not required. No individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11), (12) and (16) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state that provides coverage for prescription drugs and includes on its formulary naloxone hydrochloride or any other similarly acting and equally safe drug approved by the federal Food and Drug Administration for the treatment of drug overdose shall require prior authorization for such drug.

(P.A. 16-43, S. 2.)

History: P.A. 16-43 effective January 1, 2017.

See Sec. 38a-544b for similar provisions re group policies.

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Sec. 38a-510c. Coverage for investigational drug, biological product or device for insureds with terminal illnesses. Liability of health carrier. (a) As used in this section, “health carrier” means an insurance company, health care center, hospital service corporation, medical service corporation, fraternal benefit society or other entity that delivers, issues for delivery, renews, amends or continues a health insurance policy providing coverage of the type provided in subdivisions (1), (2), (4), (11), (12) and (16) of section 38a-469 in this state.

(b) A health carrier may provide coverage for an investigational drug, biological product or device, as defined in section 20-14q, that is made available pursuant to section 21a-70g to an insured patient who is eligible under subsection (b) of section 20-14q.

(c) A health carrier may deny coverage to an insured patient from the time such patient begins treatment with the investigational drug, biological product or device for a period not to exceed six months from the date such patient ceases treatment with the investigational drug, biological product or device, except that coverage may not be denied for a preexisting condition or for coverage for benefits that commenced prior to the date such patient begins such treatment.

(d) Nothing in this section shall affect the provisions of sections 38a-504a to 38a-504g, inclusive, and 38a-542a to 38a-542g, inclusive, concerning insurance coverage for certain costs associated with clinical trials. Treatment with an investigational drug, biological product or device shall be deemed to constitute the practice of medicine and shall not be considered a clinical trial for the purposes of said sections.

(e) Nothing in this section shall create a cause of action against a health carrier that provides coverage for an investigational drug, biological product or device pursuant to subsection (b) of this section, or denies coverage in accordance with subsection (c) of this section, to an insured patient who begins treatment with an investigational drug, biological product or device.

(P.A. 16-214, S. 3.)

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Sec. 38a-511. Copayments re in-network imaging services. (a) No health insurer, health care center, hospital service corporation, medical service corporation or fraternal benefit society that provides coverage under an individual health insurance policy or contract for magnetic resonance imaging or computed axial tomography may (1) require total copayments in excess of three hundred seventy-five dollars for all such in-network imaging services combined annually, or (2) require a copayment in excess of seventy-five dollars for each in-network magnetic resonance imaging or computed axial tomography, provided the physician ordering the radiological services and the physician rendering such services are not the same person or are not participating in the same group practice.

(b) No health insurer, health care center, hospital service corporation, medical service corporation or fraternal benefit society that provides coverage under an individual health insurance policy or contract for positron emission tomography may (1) require total copayments in excess of four hundred dollars for all such in-network imaging services combined annually, or (2) require a copayment in excess of one hundred dollars for each in-network positron emission tomography, provided the physician ordering the radiological service and the physician rendering such service are not the same person or are not participating in the same group practice.

(c) The provisions of subsections (a) and (b) of this section shall not apply to a high deductible health plan as that term is used in subsection (f) of section 38a-493.

(P.A. 06-180, S. 1; 07-54, S. 3; P.A. 10-5, S. 25; P.A. 18-68, S. 14; July Sp. Sess. P.A. 20-4, S. 25.)

History: P.A. 07-54 made technical changes in Subsecs. (a) and (b), effective May 22, 2007; P.A. 10-5 replaced reference to Sec. 38a-520 with reference to Sec. 38a-493 in Subsec. (c), effective May 5, 2010; P.A. 18-68 made a technical change in Subsec. (c); July Sp. Sess. P.A. 20-4 amended Subsec. (c) by substituting “high deductible health plan” for “high deductible plan”.

See Sec. 38a-550 for similar provisions re group policies.

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Sec. 38a-511a. Copayments re in-network physical therapy services and in-network occupational therapy services. No individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall impose copayments that exceed a maximum of thirty dollars per visit for in-network (1) physical therapy services rendered by a physical therapist licensed under section 20-73, or (2) occupational therapy services rendered by an occupational therapist licensed under section 20-74b or 20-74c.

(P.A. 13-307, S. 1; P.A. 14-97, S. 3.)

History: P.A. 13-307 effective January 1, 2015; P.A. 14-97 designated existing provisions re copayment limit for physical therapy services as Subdiv. (1) and added Subdiv. (2) re copayment limit for occupational therapy services, effective January 1, 2015.

See Sec. 38a-550a for similar provisions re group policies.

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PART III

GROUP HEALTH INSURANCE

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

(P.A. 90-243, S. 96; P.A. 03-199, S. 6; P.A. 15-118, S. 68.)

History: P.A. 03-199 deleted provision re inapplicability of Sec. 38a-546 to subscriber contracts issued by a health care center; P.A. 15-118 added “Except as otherwise provided in this title,” and made technical changes.

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Sec. 38a-512a. Continuation of coverage. (a)(1) Each insurer, health care center, hospital service corporation, medical service corporation, fraternal benefit society or other entity delivering, issuing for delivery, renewing, amending or continuing a group health insurance policy in this state that provides coverage of the type specified in subdivisions (1), (2), (3), (4), (11) and (12) of section 38a-469 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 subparagraphs (C) and (D) of this subdivision:

(A) 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 a period of thirty months after the date of such layoff, reduction of hours, leave of absence or termination of employment, 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;

(B) 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;

(C) 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;

(D) Regardless of an individual's eligibility for other group insurance, upon termination of the group policy, 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 such policy was terminated, provided claim is submitted for coverage within one year of the termination of such policy;

(E) The coverage of any covered individual shall terminate: (i) As to a child, (I) as set forth in section 38a-512b. If on the date specified for termination of coverage on a child, the child is 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 such insurer, center, corporation, society or other entity within thirty-one days of the date on which the child's coverage would have terminated in the absence of such incapacity. Such insurer, center, corporation, society or other entity 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; (ii) 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 (iii) 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;

(F) 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.

(2) Any continuation of coverage required by this subsection except subparagraph (D) or (F) of subdivision (1) 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 subparagraph (A), (B) or (E) of subdivision (1) of this subsection. The employer shall not be legally obligated by section 38a-505 or 38a-546 to pay such premium if not paid timely by the employee.

(b) Nothing in this section shall alter or impair existing group policies that have been established pursuant to an agreement that resulted from collective bargaining, and the provisions required by this section shall become effective upon the next regular renewal and completion of such collective bargaining agreement.

(P.A. 11-58, S. 44; P.A. 15-247, S. 11.)

History: P.A. 11-58 effective July 2, 2011; P.A. 15-247 deleted former Subsec. (b) re conversion privilege, and redesignated existing Subsec. (c) as Subsec. (b) and made technical changes therein, effective July 10, 2015.

See Sec. 31-51o re continuation of coverage in the event of a relocation or closing of a covered establishment.

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Sec. 38a-512b. Termination of coverage of child, stepchild or other dependent child in group policies. Dental or vision coverage. (a) Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state shall provide that coverage of a child, stepchild or other dependent child shall terminate not earlier than the policy anniversary date after the date on which the child, stepchild or other dependent child attains the age of twenty-six.

(b) Each group health insurance policy described in subsection (a) of this section, and each group health insurance policy providing coverage of the type specified in subdivision (16) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state, that includes or provides dental or vision coverage shall provide that dental or vision coverage of a child, stepchild or other dependent child shall terminate not earlier than the policy anniversary date after the date on which the child, stepchild or other dependent child attains the age of twenty-six.

(c) Each policy subject to this section shall cover a stepchild or other dependent child on the same basis as a biological child.

(e) The provisions of subsection (d) of this section shall apply to insurance policies delivered, issued for delivery, amended, renewed or continued on or after July 1, 2022.

(P.A. 11-58, S. 38; P.A. 21-149, S. 2; P.A. 22-118, S. 171.)

History: P.A. 11-58 effective July 2, 2011; P.A. 21-149 designated existing provisions re health insurance coverage for child as Subsec. (a) and amended same to add references to stepchild or other dependent child, delete provision re child becoming covered under group health plan through dependent's employment, and make technical and conforming changes, added Subsec. (b) re provisions re policy providing single ancillary dental or vision coverage, and designated existing provision requiring coverage of stepchild on same basis as biological child as Subsec. (c) and amended same to add reference to other dependent child and make technical changes, effective January 1, 2022; P.A. 22-118 added Subsec. (d) re insurance coverage for dependent child under Comptroller policy to terminate at end of calendar year of year dependent child becomes covered through own employment or attains age 26 and added Subsec. (e) re provisions of Subsec. (d) apply to policies delivered, amended, renewed or continued on or after July 1, 2022, effective July 1, 2022.

See Sec. 38a-497 for similar provisions re individual policies.

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Sec. 38a-512c. Annual and lifetime limits. (a) No 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 shall include an annual or lifetime limit on the dollar value of benefits for a covered individual, for covered benefits that are essential health benefits, as defined in (1) the Patient Protection and Affordable Care Act, P.L. 111-148, as amended from time to time, or regulations adopted thereunder, or (2) section 38a-518q, or regulations adopted thereunder.

(P.A. 11-58, S. 43; P.A. 17-15, S. 59; P.A. 18-10, S. 10.)

History: P.A. 11-58 effective July 2, 2011; P.A. 17-15 made a technical change in Subsec. (a); P.A. 18-10 amended Subsec. (a) by designating existing provisions re Affordable Care Act as Subdiv. (1), and adding Subdiv. (2) re Sec. 38a-518q and regulations adopted thereunder, effective January 1, 2019.

See Sec. 38a-482c for similar provisions re individual policies.

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Sec. 38a-513. Approval of policy forms and small employer rates. Prescription drug rebates. Medicare supplement policies. Age, gender, previous claim or medical history rating prohibited. Optional life insurance rider. Group specified disease policies. (a)(1) No group health insurance policy, as defined by the commissioner, or certificate shall be delivered or issued for delivery in this state unless a copy of the form for such policy or certificate has been submitted to and approved by the commissioner under the regulations adopted pursuant to this section. The commissioner shall adopt regulations, in accordance with the provisions of chapter 54, concerning the provisions, submission and approval of such policies and certificates and establishing a procedure for reviewing such policies and certificates. 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 that are unfair or deceptive or that encourage misrepresentation of the policy. The commissioner shall notify, in writing, the insurer that 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 order.

(2) No group health insurance policy or certificate for a small employer, as defined in section 38a-564, shall be delivered or issued for delivery in this state unless the premium rates have been submitted to and approved by the commissioner. Premium rate filings shall include the information and data required under section 38a-479qqq if the policy is subject to said section, and an actuarial memorandum that includes, but is not limited to, pricing assumptions and claims experience, and premium rates and loss ratios from the inception of the policy. Each premium rate filed on or after January 1, 2021, shall, if the insurer intends to account for rebates, as defined in section 38a-479ooo in the manner specified in section 38a-479rrr, account for such rebates in such manner, if the policy is subject to section 38a-479rrr. As used in this subdivision, “loss ratio” means the ratio of incurred claims to earned premiums by the number of years of policy duration for all combined durations.

(c) Nothing in this chapter shall preclude the issuance of a group health insurance policy that includes an optional life insurance rider, provided the optional life insurance rider shall 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.

(d) Not later than January 1, 2009, the commissioner shall adopt regulations, in accordance with chapter 54, to establish minimum standards for benefits in group specified disease policies, certificates, riders, endorsements and benefits.

(P.A. 90-243, S. 97; P.A. 93-390, S. 7, 8; P.A. 96-51, S. 3; P.A. 05-20, S. 6; P.A. 08-181, S. 6; P.A. 11-19, S. 32; P.A. 14-235, S. 28; P.A. 15-118, S. 51; 15-247, S. 7; P.A. 18-41, S. 9.)

History: P.A. 93-390 added Subsec. (b) prohibiting the incorporation of factors for age, gender, previous claim or medical condition history, into the insurer's rate schedule, effective January 1, 1994; P.A. 96-51 added Subsec. (c) to permit optional life insurance riders; P.A. 05-20 made technical changes, amended Subsec. (a) re regulations and amended Subsec. (b) to reference “determinations to grant coverage” and plans “H” to “J”, inclusive, “issued prior to January 1, 2006,” re use of claim history and medical condition, effective July 1, 2005; P.A. 08-181 added Subsec. (d) directing commissioner to adopt regulations to establish minimum benefit standards for group specified disease policies, effective June 12, 2008; P.A. 11-19 amended Subsec. (b) to delete provisions re Medicare supplement plans “H” to “J”; P.A. 14-235 made technical changes in Subsec. (c); P.A. 15-118 made technical changes in Subsecs. (a) and (b); P.A. 15-247 amended Subsec. (a) by designating existing provisions re submission and approval of policy and certificate form as Subdiv. (1) and amending same by replacing provision re issuance of order with provisions re disapproval of form, and adding Subdiv. (2) re submission and approval of small employer rates and definition of “loss ratio”, and made technical changes, effective July 10, 2015; P.A. 18-41 amended Subsec. (a)(2) by adding provisions re inclusion of information and data required under Sec. 38a-479qqq and accounting for rebates in manner specified in Sec. 38a-479rrr, effective January 1, 2020.

See Sec. 38a-477a re notification by Insurance Commissioner of required benefits and policy forms.

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Sec. 38a-513a. Time limits for coverage determinations. Notice requirements. Section 38a-513a is repealed, effective October 1, 2015.

(P.A. 99-284, S. 13; P.A. 10-24, S. 2; P.A. 11-19, S. 24; P.A. 15-118, S. 71.)

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

(P.A. 99-284, S. 16, 60; P.A. 11-58, S. 82; P.A. 12-145, S. 44.)

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

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Sec. 38a-513c. Group health insurance policy to contain definition of “medically necessary” or “medical necessity”. (a) No insurer, health care center, hospital service corporation, medical service corporation or other entity delivering, issuing for delivery, renewing, continuing or amending any group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469 in this state shall deliver or issue for delivery in this state any such policy unless such policy contains a definition of “medically necessary” or “medical necessity” as follows: “Medically necessary” or “medical necessity” means health care services that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are: (1) In accordance with generally accepted standards of medical practice; (2) clinically appropriate, in terms of type, frequency, extent, site and duration and considered effective for the patient's illness, injury or disease; and (3) not primarily for the convenience of the patient, physician or other health care provider and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness, injury or disease. For the purposes of this subsection, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community or otherwise consistent with the standards set forth in policy issues involving clinical judgment.

(P.A. 07-75, S. 2; P.A. 11-19, S. 22.)

History: P.A. 07-75 effective January 1, 2008; P.A. 11-19 made technical changes.

See Sec. 38a-482a for similar provisions re individual policies.

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Sec. 38a-513d. Insurers prohibited from issuing policy with limited coverage to employer as replacement for a comprehensive health insurance plan. Disclosure required in policy providing limited coverage. Limited coverage defined. (a) No insurer, health care center, hospital service corporation, medical service corporation or other entity delivering, issuing for delivery, renewing, continuing or amending any group health insurance policy in this state on or after January 1, 2008, shall deliver or issue for delivery in this state any policy providing limited coverage to any employer as a replacement for a comprehensive health insurance plan for its employees.

(b) Each group health insurance policy, subscriber contract or certificate of coverage delivered or issued for delivery in this state on or after January 1, 2008, that provides limited coverage, and any marketing material, application for coverage and enrollment material relative to such policy, contract or certificate, shall include the following statement printed in capital letters in not less than twelve-point boldface type and located in a conspicuous manner on such document:

(c) For the purposes of this section, “limited coverage” means an insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 that contains an annual maximum benefit of less than one hundred thousand dollars or fixed dollar benefits of less than twenty thousand dollars on any core services. For the purpose of this section, “core services” means medical, surgical and hospital services, including inpatient and outpatient physician, laboratory and imaging services.

(P.A. 07-96, S. 2; P.A. 08-147, S. 12.)

History: P.A. 07-96 effective July 1, 2007; P.A. 08-147 redefined “limited coverage” in Subsec. (c) to specify fixed dollar benefits of less than $20,000 on any core services.

See Sec. 38a-482b for similar provisions re individual policies.

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Sec. 38a-513e. Premium payment by employer following employee termination. Exceptions. Right to continuation of coverage following relocation or closing of covered establishment not affected. (a) In the event (1) an employer, as defined in section 31-58, terminates an employee for any reason other than layoff or relocation or closing of a covered establishment, as defined in section 31-51n, 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 service corporation, 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 service corporation, 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 service corporation, 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 service corporation, 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.

(c) Any right of an employee and his dependents to continuation of coverage following the relocation or closing of a covered establishment, as set forth in section 31-51o, shall not be affected by the provisions of this section.

(P.A. 09-126, S. 1; P.A. 10-5, S. 26; P.A. 15-118, S. 12.)

History: P.A. 10-5 amended Subsec. (a) to exclude termination of employee due to relocation or closing of a covered establishment from circumstances in which employer may elect not to pay health insurance premium of terminated employee, and added Subsec. (c) re right to continuation of coverage following relocation or closing of a covered establishment not affected by section, effective May 5, 2010; P.A. 15-118 made technical changes in Subsec. (a).

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Sec. 38a-513f. Claims information to be provided to certain employers. Restrictions. Subpoenas. (a) As used in this section:

(1) “Claims paid” means the amounts paid for the covered employees of an employer by an insurer, health care center, hospital service corporation, medical service corporation or other entity as specified in subsection (b) of this section for medical services and supplies and for prescriptions filled, but does not include expenses for stop-loss coverage, reinsurance, enrollee educational programs or other cost containment programs or features, administrative costs or profit.

(2) “Employer” means any town, city, borough, school district, taxing district or fire district employing more than fifty employees.

(3) “Utilization data” means (A) the aggregate number of procedures or services performed for the covered employees of the employer, by practice type and by service category, or (B) the aggregate number of prescriptions filled for the covered employees of the employer, by prescription drug name.

(b) Each insurer, health care center, hospital service corporation, medical service corporation or other entity delivering, issuing for delivery, renewing, amending or continuing in this state any group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11), (12) and (16) of section 38a-469 shall:

(1) Not later than October first, annually, provide to an employer sponsoring such policy, free of charge, the following information for the most recent thirty-six-month period or for the entire period of coverage, whichever is shorter, ending not more than sixty days prior to the date of the provision of such information, in a format as set forth in subdivision (3) of this subsection:

(A) Complete and accurate medical, dental and pharmaceutical utilization data, as applicable;

(B) Claims paid by year, aggregated by practice type and by service category, each reported separately for in-network and out-of-network providers, and the total number of claims paid;

(D) The number of insureds by coverage tier, including, but not limited to, single, two-person and family including dependents, by month;

(2) Include in such information specified in subdivision (1) of this subsection only health information that has had identifiers removed, as set forth in 45 CFR 164.514, is not individually identifiable, as defined in 45 CFR 160.103, and is permitted to be disclosed under the Health Insurance Portability and Accountability Act of 1996, P.L. 104-191, as amended from time to time, or regulations adopted thereunder; and

(3) Provide such information (A) in a written report, (B) through an electronic file transmitted by secure electronic mail or a file transfer protocol site, or (C) through a secure web site or web site portal that is accessible by such employer.

(c) Such insurer, health care center, hospital service corporation, medical service corporation or other entity shall not be required to provide such information to the employer more than once in any twelve-month period.

(d) (1) Except as provided in subdivision (2) of this subsection, information provided to an employer pursuant to subsection (b) of this section shall be used by such employer only for the purposes of obtaining competitive quotes for group health insurance or to promote wellness initiatives for the employees of such employer.

(2) Any employer may provide to the Comptroller upon request the information disclosed to such employer pursuant to subsection (b) of this section. The Comptroller shall maintain as confidential any such information.

(e) Any information provided to an employer in accordance with subsection (b) of this section or to the Comptroller in accordance with subdivision (2) of subsection (d) of this section shall not be subject to disclosure under section 1-210. An employee organization, as defined in section 7-467, that is the exclusive bargaining representative of the employees of such employer shall be entitled to receive claim information from such employer in order to fulfill its duties to bargain collectively pursuant to section 7-469.

(f) If a subpoena or other similar demand related to information provided pursuant to subsection (b) of this section is issued in connection with a judicial proceeding to an employer that receives such information, such employer shall immediately notify the insurer, health care center, hospital service corporation, medical service corporation or other entity that provided such information to such employer of such subpoena or demand. Such insurer, health care center, hospital service corporation, medical service corporation or other entity shall have standing to file an application or motion with the court of competent jurisdiction to quash or modify such subpoena. Upon the filing of such application or motion by such insurer, health care center, hospital service corporation, medical service corporation or other entity, the subpoena or similar demand shall be stayed without penalty to the parties, pending a hearing on such application or motion and until the court enters an order sustaining, quashing or modifying such subpoena or demand.

(P.A. 10-163, S. 1; P.A. 11-58, S. 10; P.A. 12-145, S. 18; P.A. 14-235, S. 66.)

History: P.A. 10-163 effective June 7, 2010; P.A. 11-58 changed “disclose” and “disclosed” to “provide” and “provided”, amended Subsec. (b) to add single service ancillary coverage to types of coverage to which section is applicable, and to require insurers to provide claims data information annually, free of charge, to employer, instead of upon request of employer, in Subdiv. (1), amended Subsec. (d) by designating existing provisions as Subdiv. (1) and adding Subdiv. (2) re provision of information to Comptroller, and made conforming changes, effective July 1, 2011; P.A. 12-145 amended Subsec. (b)(2) and (3) to delete “requested” re information, effective June 15, 2012; P.A. 14-235 amended Subsec. (b)(1) to change “request” to “provision of such information”.

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Sec. 38a-513g. Employer submission of plan cost information to Comptroller. (a) For the purposes of this section, “employer” has the same meaning as provided in section 38a-513f.

(b) Not later than October first, annually, each employer that sponsors a fully insured group health insurance policy for its active employees, early retirees and retirees that provides coverage of the type specified in subdivisions (1), (2), (4), (11), (12) and (16) of section 38a-469 shall submit electronically to the Comptroller, in a form prescribed by the Comptroller, the following information: For the two policy years immediately preceding, the percentage increase or decrease in the policy or plan costs, calculated as the total premium costs, inclusive of any premiums or contributions paid by active employees, early retirees and retirees, divided by the total number of active employees, early retirees and retirees covered by such policy.

(P.A. 11-58, S. 9.)

History: P.A. 11-58 effective July 1, 2011.

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(b) Except as provided in subsection (j) of this section, each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide benefits for the diagnosis and treatment of mental or nervous conditions. Benefits payable include, but need not be limited to: