Health Insurance Benefit Coverage Law Summaries
Connecticut, Health Insurance Benefit Coverage Law Summaries
Connecticut's mandated health care law is codified in the General Statutes of Connecticut at Title 38a, Chapters 698a and 700c. Coordination of benefits provisions are located in the Regulations of Connecticut State Agencies at Title 38a.
DEFINITIONS
A “small employer” is any person, firm, corporation, partnership, or association that has been actively engaged in business for three consecutive months that for at least 50 percent of the working days during the preceding 12 months, employed no more than 50 eligible employees, the majority of whom are employed in Connecticut. Companies that are affiliated companies or that are eligible to file a combined tax return for the state are considered one employer (Sec. 38a-564).
“Comprehensive rehabilitation services” consist of the following when provided in a comprehensive rehabilitation facility pursuant to a plan of care approved in writing by a physician licensed to practice medicine or surgery in Connecticut and reviewed by such physician at least every 30 days to determine that continuation of such services are medically necessary for the rehabilitation of the patient (Sec. 38a-523):
physician services, physical and occupational therapy, nursing care, psychological and audiological services and speech therapy provided by health care professionals who are licensed by the appropriate state licensing authority to perform such services;
social services by a social worker holding a master's degree from an accredited school of social work;
respiratory therapy by a certified respiratory therapist;
prescription drugs and medicines that cannot be self-administered;
prosthetic and orthotic devices, including the testing, fitting or instruction in the use of such devices;
other supplies or services prescribed by a physician for the rehabilitation of a patient and ordinarily furnished by a comprehensive rehabilitation facility.
Effective treatment.- Effective treatment, in terms of substance abuse coverage, means a program of therapy prescribed by a physician licensed to practice medicine or surgery under Connecticut law, and certification by such a physician of the establishment for the patient of a comprehensive follow-up program (Sec. 38a-533).
Medical social services.- Medical social services means services rendered, under the direction of a physician by a qualified social worker holding a master's degree from an accredited school of social work, including but not limited to assessment of the social, psychological and family problems related to or arising out of such covered person's illness and treatment; appropriate action and utilization of community resources to assist in resolving such problems; and participation in the development of treatment for such covered person (Secs. 38-373 and 38a-493).
Utilization review.- Utilization review is a system for prospective and concurrent review of the necessity and appropriateness in the allocation of health care resources and services given or proposed to be given to an individual within Connecticut. Utilization review does not include elective requests for clarification of coverage (Sec. 38a-226).
WHAT THE EMPLOYER MUST DO
Connecticut does not require employers to provide health insurance to their employees. However, if an employer does provide insurance, it must be aware of specific coverage required to be included in health insurance policies and contracts. This coverage is summarized below.
Mental health coverage.- No group health insurance policy, whether issued by an insurance company, a hospital service corporation, a medical service corporation or a health care center, may be delivered, issued for delivery or renewed in Connecticut, and no such policy may be amended to substantially alter or change benefits or coverages, unless persons covered under such policy will be eligible for benefits for expense arising from mental or nervous conditions that are at least equal to the following minimum requirements (Sec. 38a-514, as amended by P.A. 95-75, 95-116, and 95-289, L. 1995).
In the case of benefits based upon confinement as an inpatient in a hospital or a residential treatment facility, whether or not operated by the state, the period of confinement for which benefits will be payable must be at least 60 days in any calendar year (Sec. 38a-514, as amended by P.A. 95-75, 95-116, and 95-289, L. 1995).
In the case of benefits based upon partial hospitalization, coverage must be available for at least 120 sessions in any calendar year (Sec. 38a-514, as amended by P.A. 95-75, 95-116, and 95-289, L. 1995).
In the case of major medical expense coverage, benefits, after the applicable deductible, must be at a 50-percent rate for covered expenses incurred by the insured while other than an inpatient in a hospital or residential treatment facility, and benefits must be available for such expenses during any calendar year up to a maximum of $2,000 (Sec. 38a-514, as amended by P.A. 95-75, 95-116, and 95-289, L. 1995).
Psychologists.- In the case of benefits payable for the services of a licensed physician, such benefits must be payable for the same services when such services are lawfully rendered by a psychologist licensed under Connecticut law or by such a licensed psychologist in a licensed hospital or clinic (Sec. 38a-514, as amended by P.A. 95-75, 95-116, and 95-289, L. 1995).
Clinical social workers/marital and family therapists. - In the case of benefits payable for the services of a licensed physician or psychologist, such benefits must be payable for the same services when such services are rendered by licensed clinical social workers or licensed marital and family therapists who meet certain standards, or by independent social workers certified prior to October 1, 1990, or marriage and family therapists certified prior to October 1, 1992 (Sec. 38a-514, as amended by P.A. 95-75, 95-116, and 95-289, L. 1995).
In the case of benefits payable for the services of a licensed physician, such benefits must be payable for 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 (Sec. 38a-514, as amended by P.A. 95-75, 95-116, and 95-289, L. 1995).
In the case of benefits payable for the services of a licensed psychologist under major medical coverage, such benefits must be payable for 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 (Sec. 38a-514, as amended by P.A. 95-75, 95-116, and 95-289, L. 1995).
Outpatient services.- In the case of benefits payable under major medical coverage for the service of a licensed physician practicing as a psychiatrist or a licensed psychologist, such benefits must be payable for outpatient services rendered (Sec. 38a-514, as amended by P.A. 95-75, 95-116, and 95-289, L. 1995):
in a nonprofit community mental health center as defined by the Department of Mental Health, in a nonprofit licensed adult psychiatric clinic operated by an accredited hospital or in a residential treatment facility;
under the supervision of a licensed physician practicing as a psychiatrist, a licensed psychologist, a licensed marital and family therapist or a licensed clinical social worker; and
within the scope of the license issued to the center or clinic by the Department of Public Health and Addiction Services or to the residential treatment facility by the Department of Children and Families.
Residential treatment facilities.- Effective until January 1, 2009, in the case of benefits based upon confinement in a residential treatment facility, such benefits are payable only in situations in which (Sec. 38a-514(k), as amended by P.A. 08-125 (S. 167), L. 2008, effective January 1, 2009):
the insured has a serious mental illness that substantially impairs the person's thought, perception of reality, emotional process, or judgment or grossly impairs behavior as manifested by recent disturbed behavior;
the insured has been confined in a hospital for such illness for a period of at least three days immediately preceding such confinement in a residential treatment facility; and
such illness would otherwise necessitate continued confinement in a hospital if such care and treatment were not available through a residential treatment center for children and adolescents.
Effective January 1, 2009, in the case of benefits based upon confinement in a residential treatment facility, such benefits are payable in situations in which the insured has a serious mental or nervous condition that substantially impairs the insured's thoughts, perception of reality, emotional process or judgment or grossly impairs the behavior of the insured, and, upon an assessment of the insured by a physician, psychiatrist, psychologist or clinical social worker, cannot appropriately, safely or effectively be treated in an acute care, partial hospitalization, intensive outpatient or outpatient setting (Sec. 38a-514(k), as amended by P.A. 08-125 (S. 167), L. 2008, effective January 1, 2009).
The services rendered for which benefits are to be paid for confinement in a residential treatment facility must be based on an individual treatment plan (a treatment plan prescribed by a physician with specific attainable goals and objectives appropriate to both the patient and the treatment modality of the program) (Sec. 38a-514, as amended by P.A. 95-75, 95-116, and 95-289, L. 1995).
Exceptions.- A group health insurance policy may exclude the mental health benefits outlined above if such benefits are included in a separate policy issued to the same group by an insurance company, health care center, hospital service corporation, medical service corporation or fraternal benefit society (Sec. 38a-514, as amended by P.A. 95-75, 95-116, and 95-289, L. 1995).
Biologically-based mental or nervous conditions.- No group health insurance policy delivered, issued for delivery, renewed, amended or continued in Connecticut on or after October 1, 1997, whether issued by an insurance company, a hospital service corporation, a medical service corporation or a health care center may be delivered, issued for delivery, renewed or continued in Connecticut, and no such policy may be amended to substantially alter or change benefits or coverage unless persons covered under such policy will be eligible for expenses arising from biologically-based mental or nervous conditions that are at least equal to coverage provided for medical or surgical conditions. “Biologically-based mental illness” means the following: schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder, paranoia and other psychotic disorders, obsessive-compulsive disorder, panic disorder and pervasive developmental disorder or autism (Sec. 62, P.A. 97-8 (H. 8007), L. 1997, June 18 Special Session).
Dependent care coverage.- Every individual health insurance policy providing basic hospital expense coverage, basic medical-surgical expense coverage, major medical expense coverage, accident-only coverage, limited benefit health coverage, hospital or medical service plan contracts, or hospital and medical coverage for subscribers of a health care center for a family member of the insured or subscriber must, as to such family members' coverage, also provide that the health insurance benefits applicable for children are payable with respect to a newly born child of the insured or subscriber from the moment of birth (Sec. 38a-490).
Coverage for such newly born child must 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 (Sec. 38a-490).
Adoption.- Each group health insurance policy delivered, issued for delivery, amended, renewed or continued in Connecticut providing basic hospital expense coverage, basic medical-surgical expense coverage, major medical expense coverage, accident-only coverage, limited benefit health coverage, hospital or medical service plan contracts, or hospital and medical coverage for subscribers of a health care center, must provide coverage for a child legally placed for adoption with an employee or other member of the covered group 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 employee or member and the child is dependent upon such person for support and maintenance (Sec. 38a-549, as amended by P.A. 02-96 (H. 5644), L. 2002, effective October 1, 2002).
Coverage for such child legally placed for adoption must 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 (Sec. 38a-549, as amended by P.A. 02-96 (H. 5644), L. 2002, effective October 1, 2002).
Such policy (1) must 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 (Sec. 38a-549, as amended by P.A. 02-96 (H. 5644), L. 2002, effective October 1, 2002).
Hearing aids.- Group health insurance policies delivered, issued for delivery, renewed, amended or continued in Connecticut on or after October 1, 2001, must provide coverage for hearing aids for children 12 or younger. Such hearing aids are considered durable medical equipment, and the policy may limit the hearing aid benefit to $1,000 within a 24-month period (Sec. 16, P.A. 01-171 (S. 325), L. 2001).
Early intervention services.- Each group health insurance policy providing coverage of the type specified in Sec. 38a-469(1), (2), (4), (11) and (12) delivered, issued for delivery or renewed in Connecticut on or after July 1, 1996, shall provide coverage for medically necessary early intervention services provided as part of an individualized family service plan pursuant to Sec. 17a-248e. Such policy shall provide (1) coverage for such services provided by qualified personnel for a child from birth until the child's third birthday, and (2) a maximum benefit of $3,200 per child per year and an aggregate benefit of $9,600 per child over the total three-year period (Sec. 38a-516a, as amended by P.A. 03-3 (S. 2001), L. 2003, effective August 20, 2003).
Extended dependent coverage.- Comprehensive health care plans shall allow the following individuals to be eligible to be covered: (1) each eligible employee; (2) the spouse of each eligible employee, who shall be considered a dependent; and (3) unmarried children who are under 26 years of age (Sec. 38a-554, as amended by P.A. 08-147 (H. 5158), L. 2008, effective January 1, 2009).
The plan shall provide the option to continue coverage under each of the following circumstances until the individual is eligible for other group insurance, except as provided in items (3) and (4) below (Sec. 38a-554, as amended by P.A. 08-147 (H. 5158), L. 2008, effective January 1, 2009):
Notwithstanding any provision of this section, upon layoff, reduction of hours, leave of absence, or termination of employment, other than as a result of death of the employee or as a result of such employee's “gross misconduct” as that term is used in 29 USC 1163(2), continuation of coverage for such employee and such employee's covered dependents for the periods set forth for such event under federal extension requirements established by the federal COBRA law, 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;
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 federal COBRA law;
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 12 months from the beginning of such absence;
Regardless of an individual's eligibility for other group insurance, upon termination of the group plan, coverage for covered individuals who were totally disabled on the date of termination shall be continued without premium payment during the continuance of such disability for a period of 12 calendar months following the calendar month in which the plan was terminated, provided claim is submitted for coverage within one year of the termination of the plan;
The coverage of any covered individual shall terminate: (A) as to a child, the plan shall provide the option for said child to continue coverage for the longer of the following periods: (i) at the end of the month following the month in which the child : marries; ceases to be a resident of the state; becomes covered under a group health plan through the dependent's own employment; or attains the age of 26. The residency requirement shall not apply to dependent children under 19 years of age or full-time students attending an accredited institution of higher education. If on the date specified for termination of coverage on a child, the child is unmarried and incapable of self-sustaining employment by reason of mental or physical handicap and chiefly dependent upon the employee for support and maintenance, the coverage on such child shall continue while the plan remains in force and the child remains in such condition, provided proof of such handicap is received by the carrier within 31 days of the date on which the child's coverage would have terminated in the absence of such incapacity. The carrier may require subsequent proof of the child's continued incapacity and dependency but not more often than once a year thereafter, or (ii) for the periods set forth for such child under federal extension requirements established by the federal COBRA law; (B) as to the employee's spouse, at the end of the month following the month in which a divorce, court-ordered annulment or legal separation is obtained, whichever is earlier, except that the plan shall provide the option for said spouse to continue coverage for the periods set forth for such events under federal extension requirements established by the federal COBRA law; and (C) as to the employee or dependent who is 65 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;
As to any other event listed as a “qualifying event” in 29 USC 1163, as amended from time to time, continuation of coverage for such periods set forth for such event in 29 USC 1162, as amended from time to time, provided such plan may require the individual whose coverage is to be continued to pay up to the percentage of the applicable premium as specified for such event in 29 USC 1162, as amended from time to time. Any continuation of coverage required by this section except item (4) or (6) of this subsection may be subject to the requirement, on the part of the individual whose coverage is to be continued, that such individual contribute that portion of the premium the individual would have been required to contribute had the employee remained an active covered employee, except that the individual may be required to pay up to 102 percent of the entire premium at the group rate if coverage is continued in accordance with item (1), (2) or (5) of this subsection. The employer shall not be legally obligated by Sections 38a-505, 38a-546 and 38a-551 to 38a-559, inclusive, to pay such premium if not paid timely by the employee.
Substance abuse coverage.- Coverage for expenses incurred in connection with confinement for treatment of substance abuse or medical complications of alcoholism pursuant to diagnosis or recommendation by a physician licensed to practice medicine or surgery under Connecticut law must be provided by group health insurance policies providing the following types of coverage: basic hospital expenses, basic medical-surgical expenses, major medical expenses, accident-only, hospital or medical service plan contracts, and hospital and medical coverage provided to subscribers of a health care center (Sec. 38a-533).
Confinement for treatment of substance abuse or medical complications of alcoholism in a hospital, other than in a part of a hospital used primarily for such treatment unless otherwise provided for in such contract, must be recognized to the extent specified in the contract for confinement for any other disease (Sec. 38a-533).
Similarly, confinement in a facility established primarily for the treatment of substance abuse and licensed for such care by the state, or in a part of a hospital used primarily for such treatment, must be recognized to the extent specified in the contract, but only in connection with effective treatment of substance abuse or medical complications of alcoholism, either for a period of at least 45 days within any period of 12 consecutive months commencing with admission to such a facility or such part of a hospital or for a period of at least 45 days within any calendar year (Sec. 38a-533).
Exceptions.- A group health insurance policy may exclude coverage for substance abuse treatment if such benefits are included in a separate policy issued to the same group by an insurance company, health care center, hospital service corporation, medical service corporation or fraternal benefit society (Sec. 38a-533).
Coordination of benefits.- An employer or the insurer, managed care plan, or third-party administrator that manages a health benefit plan for an employer may share the payment of expenses with another benefit plan sponsored by another employer, with the government through Medicare benefits, or with another type of insurance company through automobile or homeowners' insurance (subrogation). To determine which plan has primary responsibility for payment, coordination of benefits (COB) language specifies the order of benefit payments. Preserving cost management initiatives, such as deductibles and coinsurance, is known as maintenance of benefits. The National Association of Insurance Commissioners (NAIC) has established model guidelines for COB which many states apply to insurance companies, HMOs, or other health care benefit providers. Self-insured employee benefit plans are not required to adopt coordination of benefits language; however, most self-insured health plans do specify how they will coordinate benefit payments with other plans.
The following types of plans may specify how benefits will be coordinated: group insurance, group subscriber contracts, uninsured arrangements of group or group-type coverages, group or group-type coverage through an HMO, and other prepayment, group practice, and individual practice plans, group-type contracts available to a membership in a particular organization or group if the individual does not have a right to maintain or renew the policy independent of continued employment with an employer, group or group-type excess hospital indemnity benefits exceeding $30 per day, group or group-type or individual “no fault ” and “fault” contracts, or Medicare or other governmental benefits. A plan does not include: individual or family insurance or subscriber contracts, individual HMO coverage, individual or family coverage through prepayment, group practice, or individual practice plans, group or group-type hospital indemnity benefits of $30 per day or less, school accident-type coverages, or a state plan under Medicaid (Regulations of Connecticut State Agencies Title 38a, Secs. 38a-480-1 - 38a-480-7).
Order of benefits.- The following priority applies when coordinating health benefit payments (Regulations of Connecticut State Agencies Secs. 38a-480-4 and 38a-480-5):
Employee/Dependent: Benefits will be paid first by a health benefit plan, HMO, or health insurance policy that covers the individual as an employee, subscriber, or member before a plan or policy that covers the individual as a dependent;
Dependent Child/Birthday Rule: For a dependent child whose parents are not separated or divorced and who is covered by two health benefit plans, HMOs, or health insurance policies, benefits will be paid first by the plan that covers the parent whose birthday month and day is earlier in the calendar year. If both parents have the same birthday, benefits will be paid first by the plan that covered a parent for a longer period of time. If only one plan specifies the birthday rule and the other plan specifies priority based on the gender of the parent, benefits will be paid first according to the order of benefits specified in the plan without the birthday rule;
Dependent Child/Divorced or Separated Parents: For a dependent child whose parents are separated or divorced and who is covered by two health benefit plans, HMOs, or health insurance policies, benefits will be paid first by the plan that covers the custodial parent, second by the plan of the spouse of the custodial parent, and third by the plan of the noncustodial parent. If a court decree states that one of the parents is responsible for health care expenses of the child, benefits will be paid first by the plan of that parent;
Active/Inactive Employee: Benefits will be paid first by a health benefit plan, HMO, or health insurance policy that covers the individual as an employee who is neither laid off or retired or as that person's dependent before a plan or policy that covers the individual as a laid-off or retired employee or dependent. If only one of the two plans specifies this rule, this standard is ignored;
Longer/Shorter Length of Coverage: Benefits will be paid first by a health benefit plan, HMO, or health insurance policy that has covered the individual as an employee, subscriber, or member for a longer period of time before a plan or policy that covered the individual for a shorter period of time; and
Excess Benefits: A complying plan may coordinate its benefits with a plan that is “excess” or “always secondary” or that uses an order of benefit determination provision that is inconsistent with that contained in this rule (called a noncomplying plan), on the following basis: if the complying plan is the primary plan, it must pay or provide its benefits on a primary basis. If the complying plan is the secondary plan, it must still pay or provide its benefits first, as the secondary plan. In such a situation, such payment is the limit of the complying plan's liability, except if the noncomplying plan does not provide the information needed by the complying plan to determine its benefits within a reasonable time after it is requested to do so, the complying plan may assume that the benefits of the noncomplying plan are identical to its own and pay its benefits accordingly. The complying plan must adjust any payments it makes based on such assumption when information becomes available about the actual benefits of the noncomplying plan. If the noncomplying plan pays less in benefits than it would have if the noncomplying plan paid or provided its benefits as the primary plan, the complying plan must advance an amount equal to such difference.
Maintenance of benefits.- A plan that pays benefits on a secondary basis may reduce benefits payable so that total benefits paid do not exceed allowable expenses (Regulations of Connecticut State Agencies Sec. 38a-480-4).
Medicare coordination.- A group contract may not reduce benefits if a person is or could be covered under another plan, except for Part B of Medicare (Regulations of Connecticut State Agencies Sec. 38a-480-4).
Providers.-Dentists.- Whenever the term “physician ” or “doctor” is used in any individual health insurance policy delivered, issued for delivery or renewed in Connecticut, it is deemed to include persons licensed 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 to practice medicine or surgery in Connecticut (Sec. 38a-491).
Chiropractors.- Every individual health insurance policy delivered, issued for delivery or renewed in Connecticut must provide coverage for services rendered by a chiropractor licensed under Connecticut law to the same extent coverage is provided for services rendered by a physician, if such chiropractic services treat a condition covered under such policy and are within those services a chiropractor is licensed to perform (Sec. 38a-507).
Nurses.- Group insurance policies delivered, issued for delivery or renewed in Connecticut providing basic hospital expense coverage, basic medical-surgical expense coverage, major medical expense coverage, accident-only coverage, limited benefit health coverage, hospital or medical service plan contracts, or hospital and medical coverage for subscribers of a health care center must provide coverage for the services of physician assistants, certified nurse practitioners, certified psychiatric-mental health clinical nurse specialists and certified nurse-midwives if such services are within the individual's area of professional competence and are currently reimbursed when rendered by any other licensed health care provider (Sec. 38a-526, as amended by P.A. 95-74, L. 1995).
Preexisting conditions.- No group health insurance plan or insurance arrangement may impose a preexisting conditions provision that excludes coverage for a period beyond 12 months following the insured's effective date of coverage. Any preexisting conditions provision may only relate to conditions, whether physical or mental, for which medical advice, diagnosis or care or treatment was recommended or received during the six months immediately before the effective date of coverage (Sec. 38a-476(b), as amended by P.A. 97-8 (H. 8007), L. 1997, June 18 Special Session).
All health insurance plans and arrangements must provide coverage for the preexisting conditions of any newly insured individual who was previously covered for such preexisting condition under the terms of the individual's preceding qualifying coverage, provided the preceding coverage was continuous to a date less than 120 days prior to the effective date of the new coverage, exclusive of any applicable waiting period, except in the case of a newly insured group member whose previous coverage was terminated due to an involuntary loss of employment, the preceding coverage must have been continuous to a date not more than 150 days prior to the effective date of the new coverage, exclusive of any applicable waiting period, provided such newly insured group member or dependent applies for such succeeding coverage within 30 days of the member's or dependent's initial eligibility (Sec. 38a-476(c), as amended by P.A. 00-121 (S. 435), L. 2000, effective October 1, 2000).
All group comprehensive health care plans must include minimum standard benefits, which may include the following provision. No preexisting condition exclusion may exclude coverage of any preexisting condition unless: (1) the condition first manifested itself within the period of six months immediately prior to the effective date of coverage in such a manner as would cause a reasonably prudent person to seek diagnosis, care or treatment; (2) medical advice or treatment was recommended or received within the period of six months immediately prior to the effective date of coverage; or (3) the condition is pregnancy existing on the effective date of coverage. No policy may exclude coverage for a loss due to preexisting conditions for a period greater than 12 months following the effective date of coverage (Sec. 38a-553, as amended by P.A. 97-8 (H. 8007), L. 1997, June 18 Special Session).
Small employers.- Blue ribbon health care plans for small employers may include utilization review, including review of medical necessity of hospital and physician services, case management, and other managed care provisions (Secs. 38a-564 -38a-568).
Breast cancer.- No group health insurance plan may refuse to cover a group health insurance applicant due to breast cancer if the applicant has remained free from breast cancer for at least five years prior to the applicant's request for group health insurance coverage (Sec. 38a-530a, as added by P.A. 96-177, L. 1996, effective October 1, 1996).
Metabolic disorders/specialized formulas.- Group health insurance policies delivered, issued for delivery or renewed in Connecticut on or after October 1, 1997, must provide coverage for amino acid modified preparations and low protein modified food products for the treatment of inherited metabolic diseases (including cystic fibrosis) if the preparations or products are prescribed for the therapeutic treatment of inherited metabolic diseases and are administered under the direction of a physician (Sec. 38a-518c, as amended by P.A. 07-197 (S. 66), L. 2007, effective October 1, 2007).
Group health insurance policies delivered, issued for delivery or renewed in Connecticut on or after October 1, 2007, must provide coverage for specialized formulas when such formulas are medically necessary for the treatment of a disease or condition and are administered under the direction of a physician “Specialized formula” means a nutritional formula for children up to age 12 that is exempt from the general requirements for nutritional labeling under the statutory and regulatory guidelines of the FDA and is intended for use solely under medical supervision in the dietary management of specific diseases (Sec. 38a-518c, as amended by P.A. 07-197 (S. 66), L. 2007, effective October 1, 2007).
Accidental ingestion/consumption of controlled drugs.- No individual health insurance policy providing basic hospital expense coverage, basic medical-surgical expense coverage, major medical expense coverage, accident-only coverage, limited benefit health coverage, or hospital or medical service plan contracts may be delivered, issued for delivery or renewed in Connecticut, or amended to substantially alter or change benefits or coverage, 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, which are at least equal to the following minimum requirements (Sec. 38a-492):
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 will be payable must be at least 30 days in any calendar year.
For covered expenses incurred by the insured while other than an inpatient in a hospital, benefits must be available for such expenses during any calendar year up to a maximum of $500.
Persons with elevated blood alcohol content.- No group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of Sec. 38a-469 delivered, issued for delivery, amended, renewed or continued in this state on or after October 1, 2006, 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 (Sec. 2, P.A. 06-39 (S. 425), L. 2006).
Mammograms.- Each group health insurance policy delivered, issued for delivery, renewed, amended or continued in Connecticut on or after October 1, 2001, must provide benefits for mammographic examinations to any woman covered under the policy that are at least equal to the following minimum requirements (Sec. 38a-530(a), as amended by P.A. 06-38 (S. 422), L. 2006, effective October 1, 2006):
a baseline mammogram for any woman who is 35 to 39 years of age, inclusive; and
a mammogram every year for any woman who is 40 years of age or older.
Such policy shall provide additional benefits for comprehensive ultrasound screening of an entire breast or breasts if a mammogram demonstrates heterogeneous or dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology or if a woman is believed to be at increased risk for breast cancer due to family history or prior personal history of breast cancer, positive genetic testing or other indications as determined by a woman's physician or advanced practice registered nurse (Sec. 38a-530(a), as amended by P.A. 06-38 (S. 422), L. 2006, effective October 1, 2006).
Mastectomies.- Group health insurance policies providing basic hospital expense coverage, basic medical-surgical expense coverage, major medical expense coverage, limited benefit health coverage, hospital or medical service plan contracts, and hospital and medical coverage for subscribers of a health care center that are delivered, issued for delivery, amended, renewed or continued in Connecticut on or after July 1, 1997, must provide coverage for at least 48 hours of inpatient care following a mastectomy or lymph node dissection, and must 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 if the patient's treating physician recommends such outpatient surgery or shorter inpatient care after conferring with the patient (Sec. 2, P.A. 97-198 (S. 334), L. 1997, effective July 1, 1997).
Reconstructive surgery.- Coverage must be provided 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 (Sec. 38a-542, as amended by P.A. 97-198 (S. 334), L. 1997, effective July 1, 1997).
Prescription birth control.- Group insurance policies delivered, issued for delivery, renewed or continued in Connecticut on or after October 1, 1999, that provide coverage for outpatient prescription drugs approved by the federal Food and Drug Administration must not exclude coverage for prescription contraceptive methods approved by the FDA. However, any insurance company, hospital or medical service corporation, or health care center may issue to a religious employer a group health insurance policy that excludes coverage for prescription contraceptive methods that are contrary to the religious employer's bona fide religious tenets (Sec. 2, P.A. 99-79 (H. 5950), L. 1999).
Infertility treatment.- Subject to specified limitations and exceptions, group health insurance policies issued for delivery, amended, renewed or continued in this state on or after October 1, 2005, 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 a presumably healthy individual who is unable to conceive or produce conception or sustain a successful pregnancy during a one-year period. Any insurance company, hospital or medical service corporation, or health care center may issue to a religious employer a group 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. 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 or 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 (P.A. 05-196 (S. 508), L. 2005, effective October 1, 2005).
Any health insurance policy issued pursuant to the religious employer exception as described just above 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 10-point type, in the policy, application and sales brochure for such policy (P.A. 05-196 (S. 508), L. 2005, effective October 1, 2005).
Maternity benefits.- Each group insurance carrier that offers maternity benefits must provide coverage of a minimum of 48 hours of inpatient care for a mother and her newborn infant following a vaginal delivery and a minimum of 96 hours of inpatient care following a caesarean delivery. Any decision to shorten the length of inpatient stay must be made by the attending health care providers after conferring with the mother, and in the event of a shortened stay, coverage must be provided for follow-up visits. Carriers must provide written notice of this coverage to policyholders (Sec. 38a-530c, as added by P.A. 96-177, L. 1996, effective May 24, 1996).
Breast implant removal.- Any insurance company, hospital service corporation, medical service corporation, health care center or fraternal benefit society that delivers or issues for delivery in Connecticut group health insurance policies providing basic hospital expense coverage, basic medical-surgical expense coverage, major medical expense coverage, hospital or medical service plan contracts, or hospital and medical coverage for subscribers of a health care center, must provide coverage under such policies for the costs of removal of any breast implant that was implanted on or before July 1, 1994, without regard to the purpose of such implantation, which removal is determined to be medically necessary. Coverage must provide at least a yearly benefit of $1,000 for the costs of removal of any breast implant (Sec. 38a-542, as amended by P.A. 97-198 (S. 334), L. 1997, effective July 1, 1997).
Diabetes.- Group health insurance policies delivered, issued for delivery or renewed in Connecticut on or after October 1, 1997, must provide coverage for laboratory and diagnostic tests for all types of diabetes, as well as medically necessary treatment of insulin-dependent diabetes, insulin-using diabetes, gestational diabetes and non-insulin-using diabetes (Sec. 5, P.A. 97-268 (H. 6266), L. 1997, effective October 1, 1997).
Ostomies.- Group health insurance policies delivered, issued for delivery, renewed or continued in Connecticut on or after October 1, 2000, that provide coverage for ostomy surgery must include coverage, up to $1,000 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 (Sec. 2, P.A. 00-63 (H. 5120), L. 2000).
Colorectal cancer screenings.- Group health insurance policies delivered, issued for delivery, amended or renewed or continued in Connecticut on or after October 1, 2001, must provide coverage for colorectal cancer screening (Sec. 21, P.A. 01-171 (S. 325), L. 2001).
Cancer clinical trials.- Group insurance policies delivered, issued for delivery, or renewed in Connecticut on or after January 1, 2002, must provide coverage for routine patient care costs associated with cancer clinical trials (P.A. 01-171 (S. 325), L. 2001).
Ambulance services.- Group health insurers must provide coverage for medically necessary ambulance services for persons covered by the policy. The policy must, 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 policies need not provide benefits in excess of the maximum allowable rate established by the Department of Public Health (Sec. 38a-525, as amended by P.A. 02-124 (H. 5566), L. 2002, effective October 1, 2002).
Home health care benefits.- Every individual health insurance policy delivered, issued for delivery or renewed in Connecticut providing basic hospital expense coverage, basic medical-surgical expense coverage, major medical expense coverage, accident-only coverage, limited benefit health coverage, hospital or medical service plan contracts, or hospital and medical coverage for subscribers of a health care center must provide coverage providing reimbursement for home health care to Connecticut residents. Home health care must be provided by a home health agency (Sec. 38a-493).
Home health care must consist of, but is not limited to, the following (Sec. 38a-493):
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;
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;
physical, occupational or speech therapy;
medical supplies, drugs and medicines prescribed by a physician 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;
medical social services provided to or for the benefit of a covered person diagnosed by a physician as terminally ill with a prognosis of six months or less to live.
The number of home health care visits may not be less than 80 in any calendar year or in any continuous period of 12 months for each person covered under a policy or contract, except in the case of a covered person diagnosed by a physician as terminally ill with a prognosis of six months or less to live, the yearly benefit for medical social services must not exceed $200 (Sec. 38a-493).
Extended care.- Long-term care policies must provide benefits for confinement in a nursing home or confinement in the insured's own home, or both (Sec. 38a-501).
Rehabilitation services.- Any insurance company, hospital or medical service corporation or health care center authorized to do the business of health insurance in Connecticut must offer to any individual, partnership, corporation or unincorporated association providing group health insurance coverage of the following types a group hospital or medical service plan or contract providing coverage for expenses incurred for comprehensive rehabilitation services under such terms and conditions as are agreed to by the policyholder and the insurer: basic hospital expense coverage, basic medical-surgical expense coverage, major medical expense coverage, accident-only coverage, hospital or medical service plan contracts, or hospital and medical coverage for subscribers of a health care center (Sec. 38a-523).
Occupational therapy.- Every individual health insurance policy delivered, issued for delivery or renewed in Connecticut providing basic hospital expense coverage, basic medical-surgical expense coverage, major medical expense coverage, accident-only coverage, limited benefit health coverage, hospital or medical service plan contracts, or hospital and medical coverage for subscribers of a health care center, that provides coverage for expenses incurred for physical therapy must provide coverage for occupational therapy provided in private practice or in a health care facility or in a partial hospitalization program on an exchange basis (Sec. 38a-496).
Autism spectrum disorder.- Effective January 1, 2009, group health insurers will be required to provide coverage for physical therapy, speech therapy and occupational therapy services for the treatment of autism spectrum disorders, as set forth in the most recent edition of the American Psychiatric Association's “Diagnostic and Statistical Manual of Mental Disorders”, to the extent such services are a covered benefit for other diseases and conditions (Sec. 2, P.A. 08-132 (H. 5696), L. 2008, enacted June 5, 2008).
Work-related injuries.- No individual health insurance policy delivered, issued for delivery, amended or renewed in Connecticut providing basic hospital expense coverage, basic medical-surgical expense coverage, major medical expense coverage, accident-only coverage, limited benefit health coverage, hospital or medical service plan contracts, or hospital and medical coverage for subscribers of a health care center 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 (Sec. 38a-500):
a sole proprietor or business partner who is not covered by the Connecticut Workers' Compensation Law or who accepts the provisions of such law; or
an employee of a corporation and who is a corporate officer, regardless of any election by such individual to be excluded from coverage under Connecticut's Workers' Compensation Law.
Tumors/leukemia.- Any insurance company, hospital service corporation, medical service corporation, health care center or fraternal benefit society that delivers or issues for delivery in Connecticut group health insurance policies providing basic hospital expense coverage, basic medical-surgical expense coverage, major medical expense coverage, hospital or medical service plan contracts, or hospital and medical coverage for subscribers of a health care center, must 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 maxillofacial prosthesis used to replace anatomic structures lost during treatment for head and neck tumors or additional appliances essential for the support of such prosthesis, and outpatient chemotherapy following surgical procedures in connection with the treatment of tumors (Sec. 38a-542, as amended by P.A. 97-198 (S. 334), L. 1997, effective July 1, 1997).
The coverage must provide at least a yearly benefit of $500 for the surgical removal of tumors, $500 for reconstructive surgery, $500 for outpatient chemotherapy and $300 for prosthesis, except that for purposes of the surgical removal of breasts due to tumors, the yearly benefit for prosthesis shall be at least $300 for each breast removed (Sec. 38a-542, as amended by P.A. 97-198 (S. 334), L. 1997, effective July 1, 1997).
It must also cover a wig if prescribed by a licensed oncologist for a patient who suffers hair loss as a result of chemotherapy, with a benefit of at least $350 (Sec. 38a-542, as repealed and substituted by P.A. 04-34 (H. 5464), L. 2004).
Minimum basic benefit policies.- All group comprehensive health care plans must include minimum standard benefits as described below (Sec. 38-373).
Minimum standard benefits are benefits, including coverage for catastrophic illness, with a lifetime maximum of $1,000,000 per individual, for reasonable charges or, when applicable, the allowance agreed upon between a provider and a carrier for charges actually incurred, for the following health care services, rendered to an individual covered by such plan for the diagnosis or treatment of nonoccupational disease or injury (Sec. 38-373):
hospital services;
professional services rendered by a physician or, at his or her direction, by a registered nurse, other than services for mental or dental conditions;
the diagnosis or treatment of mental conditions;
legend drugs requiring a physician's prescription;
services of a skilled nursing facility for not more than 120 days in a calendar year, provided such services commence within 14 days following a confinement of at least three consecutive days in a hospital for the same condition;
home health agency services, up to a maximum of 180 visits in a calendar year, provided such services commence within seven days following confinement in a hospital or skilled nursing facility of at least three consecutive days for the same condition, provided further, in the case of an individual diagnosed by a physician as terminally ill with a prognosis of six months or less to live, such home health agency services may commence irrespective of whether such covered person was so confined or, if such covered person was so confined, irrespective of such seven-day period, and the yearly benefit for medical social services may not exceed $200;
use of radium or other radioactive materials;
outpatient chemotherapy for the removal of tumors and treatment of leukemia, including outpatient chemotherapy;
oxygen;
anesthetics;
nondental prosthesis and maxillofacial prosthesis used to replace any anatomic structure lost during treatment for head and neck tumors or additional appliances essential for the support of such prosthesis;
rental of durable medical equipment that has no personal use in the absence of the condition for which prescribed;
specified diagnostic x-rays and laboratory tests;
oral surgery for excision of partially or completely unerupted impacted teeth, or excision of a tooth root without the extraction of the entire tooth;
services of a licensed physical therapist, rendered under the direction of a physician;
transportation by a local professional ambulance to the nearest health care institution qualified to treat the illness or injury;
certain other services that are medically necessary in the treatment or diagnosis of an illness or injury as may be designated or approved by the Insurance Commissioner;
confinement for a period of at least 45 days within any calendar year in a facility established primarily for the treatment of alcoholism and licensed for such care by the state, or in a part of a hospital used primarily for such treatment.
Exceptions.- Plans providing minimum standard benefits need not provide benefits for the following (Sec. 38-373):
any charge for any care for any injury or disease either (a) arising out of and in the course of an employment subject to a workers' compensation or similar law or where such benefit is required to be provided under a workers' compensation policy to a sole proprietor, business partner or corporation officer who elects such coverage pursuant to Connecticut's workers' compensation law or (b) to the extent benefits are payable without regard to fault under a coverage statutorily required to be contained in any motor vehicle or other liability insurance policy or equivalent self-insurance;
any charge for treatment for cosmetic purposes other than surgery for the prompt repair of an accidental injury sustained while covered, provided cosmetic does not mean replacement of any anatomic structure removed during treatment of tumors;
any charge for travel, other than transportation by local professional ambulance to the nearest health care institution qualified to treat the illness or injury;
any charge for private room accommodations to the extent it is in excess of the institution's most common charge for a semiprivate room;
any charge by health care institutions to the extent that it is determined by the carrier that the charge exceeds the rates approved by the Commission on Hospital and Health Care;
any charge for services or articles to the extent that it exceeds the reasonable charge in the locality for the service;
any charge for services or articles determined not to be medically necessary;
any charge for services or articles the provisions of which is not within the scope of the license or certificate of the institution or individual rendering such services or articles;
any charge for services or articles furnished, paid for or reimbursed directly by or under any law of a government, except as otherwise provided by law;
any charge for services or articles for custodial care or designed primarily to assist an individual in meeting his or her activities of daily living;
any charge for services that would not have been made if no insurance existed or for which the covered individual is not legally obligated to pay;
any charge for eyeglasses, contact lenses or hearing aids or the fitting thereof;
any charge for dental care not specifically covered by Title 38a; and
any charge for services of a registered nurse who ordinarily resides in the covered individual's home, or who is a member of the covered individual's family or the family of the covered individual's spouse.
Craniofacial disorders.- Group health insurers shall provide coverage for medically necessary orthodontic processes and appliances for the treatment of craniofacial disorders for individuals 18 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 (Sec. 2, P.A. 03-37 (S. 1), L. 2003, effective October 1, 2003).
Dental services.- Group health insurers must provide coverage for general anesthesia, nursing and related hospital services provided in conjunction with inpatient, outpatient, or one-day dental services if the following conditions are met (Sec. 38a-517a, as amended by P.A. 03-58 (S. 918), L. 2003, effective October 1, 2003):
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
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.
Veterans' Home and Hospital services.- No individual health insurance policy delivered, issued for delivery or renewed in Connecticut may exclude coverage for services provided by the Veterans' Home and Hospital (Sec. 38a-502).
Utilization review. -Certification of UR agents.- To promote delivery of quality health care in a cost-effective manner, assure that utilization review agents adhere to reasonable standards, foster coordination and cooperation between health care providers and utilization review agents, improve communication among all parties, and ensure that medical records are kept confidential, Connecticut requires utilization review agents to be certified annually and adhere to minimum standards (Secs. 38a-226 -226d). Those UR agents who have received accreditation by the Utilization Review Accreditation Commission (URAC) are exempt from paying a fee (Sec. 38a-226d). Violations will be addressed by the Commissioner, who may order payment of a penalty fine or suspend or revoke the certification of the UR agent (Sec. 38a-226b).
Standards for UR agents.- UR agents must meet the following standards (Sec. 28a-226c):
mail or communicate a notification of a determination to the health care provider or other appropriate individual within two business days of receipt of all information needed to complete the review;
determine the necessity or appropriateness of an admission, service, or procedure in accordance with a physician's guidelines or have a physician perform the review;
include the principal reason for the determination and the procedures to initiate an appeal with any notification of denial of certification of an admission, service, or procedure;
maintain and make available a written description of the appeal procedure by which the enrolled individual or the provider of record may seek review of a determination by the UR agent. The appeal procedure must provide that: (a) on appeal, all determinations not to certify an admission, service, or procedure as being necessary or appropriate will be made by a physician in the same or a similar general specialty as typically manages the medical condition, procedure or treatment under discussion as mutually deemed appropriate; (b) UR agents will complete the appeals determinations no later than 30 days from the date the appeal is filed and the receipt of all information needed; and (c) when an initial determination not to certify a health care service is made prior to or during an ongoing service requiring review, and the attending physician believes that the determination warrants immediate appeal, the attending physician will have an opportunity to appeal that determination over the telephone on an expedited basis. UR agents will complete the adjudication on an expedited basis within 48 hours of the date the appeal is filed and the receipt of all information necessary to complete the appeal. Expedited appeals that do not resolve a difference of opinion may be resubmitted through the standard appeal process;
have staff available by toll-free telephone at least 40 hours per week during normal business hours;
use written clinical criteria and review procedures established and periodically reviewed by practitioners;
protect the confidentiality of individual medical records;
hire physicians, nurses, or others making utilization review decisions with current state licenses;
allow a minimum of 24 hours after an emergency admission, service, or procedure for notification of the UR agent and request certification or continuing treatment for that condition;
work on hospital premises with the permission of the hospital during reasonable business hours;
be provided by the provider of record with all relevant information to certify an admission, procedure, treatment, or length of stay;
not receive from providers or enrollees fraudulent or misleading information.
Civil unions.- Parties to a civil union shall have all the same benefits, protections and responsibilities under law, whether derived from the general statutes, administrative regulations or court rules, policy, common law or any other source of civil law, as are granted to spouses in a marriage (Sec. 46b-38nn, as amended by File No. 680 (S. 899), L. 2009, effective from April 23, 2009, until October 1, 2010).
Until October 1, 2010, wherever in the general statutes the terms “spouse,” “family,” “immediate family,” “dependent,” “next of kin,” or any other term that denotes the spousal relationship are used or defined, a party to a civil union shall be included in such use or definition, and wherever in the general statutes, with specified exceptions, the term “marriage” is used or defined, a civil union shall be included in such use or definition. Wherever in the general statutes, with specified exceptions, the term “marital status” is used or defined, civil union status shall be included in such use or definition (Sec. 46b-38oo, repealed October 1, 2010).
Until October 1, 2010, a person is eligible to enter into a civil union if such person is (Sec. 46b-38bb, repealed October 1, 2010):
not a party to another civil union or a marriage;
of the same sex as the other party to the civil union;
at least 18 years of age; and
is not a relative of the other party as described in the law.
WHO TO CONTACT
Contact the State of Connecticut Insurance Department at 153 Market St., 7th Floor, Hartford, CT 06103. Telephone: 1-860-297-3800.
<p>Contact the State of Connecticut Insurance Department at 153 Market St., 7th Floor, Hartford, CT 06103. Telephone: 1-860-297-3800.</p>
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