Sec. 38a-553. (Formerly Sec. 38-373). Minimum standard benefits of comprehensive health care plans. Optional and excludable benefits. Preexisting conditions. Use of managed care plans. - Connecticut Statutes

      Sec. 38a-553. (Formerly Sec. 38-373). Minimum standard benefits of comprehensive health care plans. Optional and excludable benefits. Preexisting conditions. Use of managed care plans. All individual and all group comprehensive health care plans shall include minimum standard benefits as described in this section.

      (a) Except as provided in subsections (b) and (c), minimum standard benefits shall be benefits, including coverage for catastrophic illness, with a lifetime maximum of one million dollars 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: (1) Hospital services; (2) professional services which are rendered by a physician or, at his direction, by a registered nurse, other than services for mental or dental conditions; (3) the diagnosis or treatment of mental conditions, in accordance with the minimum requirements established in section 38a-514; (4) legend drugs requiring a prescription of a physician, advanced practice registered nurse or physician assistant; (5) services of a skilled nursing facility for not more than one hundred twenty days in a calendar year, provided such services commence within fourteen days following a confinement of at least three consecutive days in a hospital for the same condition; (6) home health agency services, as defined by the commissioner, up to a maximum of one hundred eighty 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, as hereinafter defined, shall not exceed two hundred dollars. "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 (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; (C) participation in the development of treatment for such covered person; (7) use of radium or other radioactive materials; (8) outpatient chemotherapy for the removal of tumors and treatment of leukemia, including outpatient chemotherapy; (9) oxygen; (10) anesthetics; (11) nondental prosthesis and maxillo-facial 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; (12) rental of durable medical equipment which has no personal use in the absence of the condition for which prescribed; (13) diagnostic x-rays and laboratory tests as defined by the commissioner; (14) oral surgery for: (A) Excision of partially or completely unerupted impacted teeth, or (B) excision of a tooth root without the extraction of the entire tooth; (15) services of a licensed physical therapist, rendered under the direction of a physician; (16) transportation by a local professional ambulance to the nearest health care institution qualified to treat the illness or injury; (17) certain other services which are medically necessary in the treatment or diagnosis of an illness or injury as may be designated or approved by the Insurance Commissioner; (18) confinement 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, shall be a covered expense for a period of at least forty-five days within any calendar year.

      (b) Minimum standard benefits may include one or more of the following provisions: (1) For policies issued or renewed prior to April 1, 1994, subject to the provisions of subdivision (3) such plan may require deductibles. The "low option deductible" shall be two hundred dollars per person, the "middle option deductible" shall be five hundred dollars per person, and the "high option deductible" shall be seven hundred fifty dollars per person. The amount of the deductible may not be greater when a service is rendered on an outpatient basis than when that service is offered on an inpatient basis. Expenses incurred during the last three months of a calendar year and actually applied to an individual's deductible for that year shall be applied to that individual's deductible in the following calendar year. The two-hundred-dollar maximum, the five-hundred-dollar maximum and the seven-hundred-fifty-dollar maximum may be adjusted yearly to correspond with the change in the medical care component of the Consumer Price Index, as adjusted by the commissioner. The base year for such computation shall be the first full year of operation of such plan. (2) For policies issued or renewed prior to April 1, 1994, subject to the provisions of subdivision (3), such plan shall require a maximum copayment of twenty per cent for charges for all types of health care in excess of the deductible and fifty per cent for services listed in subdivision (3) of subsection (a) in excess of the deductible. (3) The sum of any deductible and copayments required in any calendar year may not exceed a maximum limit of one thousand dollars per covered individual, or two thousand dollars per covered family; provided, covered expenses incurred after the applicable maximum limit has been reached shall be paid at the rate of one hundred per cent, except that expenses incurred for treatment of mental and nervous conditions may be paid at the rate of fifty per cent as specified in subdivision (3) of subsection (a). The one-thousand-dollar and two-thousand-dollar maximums shall be adjusted yearly to correspond with the change in the medical care component of the Consumer Price Index as adjusted by the commissioner. (4) The plan shall limit benefits with respect to each pregnancy, other than a pregnancy involving complications of pregnancy, to a maximum of two hundred fifty dollars. (5) The plan may limit lifetime benefits to a maximum of not less than one million dollars per covered individual. (6) No preexisting condition exclusion shall exclude coverage of any preexisting condition unless: (A) 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; (B) medical advice or treatment was recommended or received within the period of six months immediately prior to the effective date of coverage; or (C) the condition is pregnancy existing on the effective date of coverage. No policy shall exclude coverage for a loss due to preexisting conditions for a period greater than twelve months following the effective date of coverage. Any individual comprehensive health care plan issued as a result of conversion from group health insurance or from a self-insured group shall credit the time covered under such group health insurance toward any such exclusion.

      (c) Plans providing minimum standard benefits need not provide benefits for the following: (1) 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 the provisions of chapter 568 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; (2) any charge for treatment for cosmetic purposes other than surgery for the prompt repair of an accidental injury sustained while covered, provided cosmetic shall not mean replacement of any anatomic structure removed during treatment of tumors; (3) any charge for travel, other than transportation by local professional ambulance to the nearest health care institution qualified to treat the illness or injury; (4) any charge for private room accommodations to the extent it is in excess of the institution's most common charge for a semiprivate room; (5) 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 Office of Health Care Access; (6) any charge for services or articles to the extent that it exceeds the reasonable charge in the locality for the service; (7) any charge for services or articles which are determined not to be medically necessary, except that this shall not apply to the fabrication or placement of the prosthesis as specified in subdivision (11) of subsection (a) of this section and subdivision (2) of this subsection; (8) 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; (9) any charge for services or articles furnished, paid for or reimbursed directly by or under any law of a government, except as otherwise provided herein; (10) any charge for services or articles for custodial care or designed primarily to assist an individual in meeting his activities of daily living; (11) any charge for services which would not have been made if no insurance existed or for which the covered individual is not legally obligated to pay; (12) any charge for eyeglasses, contact lenses or hearing aids or the fitting thereof; (13) any charge for dental care not specifically covered by sections 38a-505, 38a-546 and 38a-551 to 38a-559, inclusive; and (14) 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.

      (d) and (e) Repealed by P.A. 84-499, S. 2.

      (f) The minimum standard benefits of any individual or group comprehensive health care plan may be satisfied by catastrophic coverage offered in conjunction with basic hospital or medical-surgical plans on an expense incurred or service basis as approved by the commissioner as providing at least equivalent benefits.

      (g) Comprehensive health care plan carriers may offer alternative policy provisions and benefits, including cost containment features, consistent with the purposes of sections 38a-505, 38a-546 and 38a-551 to 38a-559, inclusive, provided such alternative provisions and benefits are approved by the Insurance Commissioner prior to their use. Cost containment features may include, but shall not be limited to, preferred provider provisions; utilization review of health care services, including review of the medical necessity of hospital and physician services; case management benefit alternatives; and other managed care provisions.

      (h) Every comprehensive health care plan issued or renewed through the Health Reinsurance Association on or after April 1, 1994, shall be a managed care plan. Such managed care plans shall include one or more health care center plans or preferred provider network plans, as determined by the board of the association, with the approval of the commissioner. In the event that such managed care plans would not adequately serve enrollees in a particular area of the state, the board may offer to such enrollees a managed care product which contains alternative cost containment features, including but not limited to, utilization review of health care services, review of the medical necessity of hospital and physician services and case management benefit alternatives.

      (i) No comprehensive health care plan issued through the Health Reinsurance Association to a HIPAA eligible individual shall include any limitation or exclusion of benefits based on a preexisting condition.

      (j) No comprehensive health care plan issued through the Health Reinsurance Association to a health care tax credit eligible individual shall include any limitation or exclusion of benefit based on a preexisting condition if such individual maintained creditable health insurance coverage for an aggregate period of three months as of the date on which the individual seeks to enroll in the Health Reinsurance Association issued plan, not counting any period prior to a sixty-three-day break in coverage.

      (k) (1) Each comprehensive health care plan issued through the Health Reinsurance Association shall provide coverage, under the terms and conditions of the plan, for the preexisting conditions of any group member or dependent who is newly insured under the plan on or after October 1, 2005, and was previously covered for such preexisting condition under the terms of the group member's or dependent's preceding qualifying coverage, provided the preceding qualifying coverage was continuous to a date less than one hundred twenty 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 preceding qualifying coverage was terminated due to an involuntary loss of employment, the preceding qualifying coverage must have been continuous to a date not more than one hundred fifty days prior to the effective date of the new coverage under the plan, exclusive of any applicable waiting period, provided the requirements of this subdivision shall only apply if the newly insured group member or dependent applies for such succeeding coverage not later than thirty days after the first day of the member's or dependent's initial eligibility.

      (2) With respect to a group member or dependent who was newly insured under the plan on or after October 1, 2005, and was previously covered under qualifying coverage, but was not covered under such qualifying coverage for a preexisting condition, as defined under the newly issued comprehensive health care plan, such plan shall credit the time such group member or dependent was previously covered by qualifying coverage to the exclusion period of the preexisting condition provision, provided the preceding qualifying coverage was continuous to a date less than one hundred twenty days prior to the effective date of the new coverage, exclusive of any applicable waiting period under such plan, except in the case of a newly insured group member whose preceding qualifying coverage was terminated due to an involuntary loss of employment, the preceding qualifying coverage must have been continuous to a date not more than one hundred fifty days prior to the effective date of the new coverage, exclusive of any applicable waiting period, provided the requirements of this subdivision shall only apply if such newly insured group member or dependent applies for such succeeding coverage not later than thirty days after the first day of the member's or dependent's initial eligibility.

      (3) As used in this subsection, "qualifying coverage" means coverage under (A) any group health insurance plan, group insurance arrangement or self-insured plan covering a group, (B) Medicare or Medicaid, or (C) an individual health insurance plan that provides benefits which are actuarially equivalent to or exceeding the benefits provided under a small employer health care plan, as defined in section 38a-564, whether issued in this state or any other state, as determined by the Insurance Department.

      (P.A. 75-616, S. 3, 12; P.A. 76-399, S. 3, 5; P.A. 77-614, S. 163, 610; P.A. 78-76, S. 4; P.A. 79-327, S. 1; 79-376, S. 67; P.A. 80-482, S. 332, 348; P.A. 81-55; P.A. 82-112; P.A. 84-499, S. 2; P.A. 89-80; P.A. 93-338, S. 2; P.A. 95-257, S. 39, 58; P.A. 96-19, S. 8; June 18 Sp. Sess. P.A. 97-8, S. 68, 88; June 30 Sp. Sess. P.A. 03-6, S. 67; P.A. 04-10, S. 12; P.A. 05-271, S. 1.)

      History: P.A. 76-399 added Subsec. (a)(17)) re coverage pertaining to treatment of alcoholism and added provisions re pregnancy benefits in Subsec. (b); P.A. 77-614 placed insurance commissioner within the department of business regulation and made insurance department a division within that department, effective January 1, 1979; P.A. 78-76 added proviso in Subsec. (a)(6) re coverage of medical social services where patient is terminally ill; P.A. 79-327 inserted new Subdiv. (8) in Subsec. (a) re outpatient chemotherapy and deleted former Subdiv. (16) re unspecified services left to insurance commissioner's discretion, renumbering as necessary and included maxillo-facial prostheses in Subdiv. (11), formerly (10), amending Subsec. (c) re prostheses accordingly; P.A. 79-376 replaced "workmen's compensation" with "workers' compensation" in Subsec. (c)(1); P.A. 80-482 restored insurance commissioner and division to prior independent status and abolished the department of business regulation; P.A. 81-55 amended Subsec. (c), providing that comprehensive health care plans are not obligated to provide benefits for care for injury or disease where benefits must be provided to a sole proprietor or partner under a workers' compensation policy; P.A. 82-112 provided that comprehensive health care plans need not provide benefits when such benefit is required under workers' compensation for corporation officers in Subsec. (c) and enumerated certain circumstances under which carriers shall not deny benefits in new Subsec. (d), relettering former Subsecs. (d) and (e) accordingly; P.A. 84-499 repealed Subsecs. (d) and (e) re denial of benefits and carriers' rights of recovery; P.A. 89-80 added Subsec. (g) allowing alternative provisions and benefits, including cost containment features, to be offered if approved by the commissioner; Sec. 38-373 transferred to Sec. 38a-553 in 1991; P.A. 93-338 in Subsec. (a)(3) changed the provisions re minimum standard benefits for mental illness conditions, in Subsec. (b) specified that Subdivs. (1) and (2) apply to policies issued or renewed prior to April 1, 1994, and added new Subsec. (h) requiring that every plan issued or renewed through the Health Reinsurance Association on or after April 1, 1994, be a managed care plan; P.A. 95-257 replaced Commission on Hospitals and Health Care with Office of Health Care Access, effective July 1, 1995; P.A. 96-19 amended Subsec. (a) to include prescriptions by advanced practice registered nurses and physician assistants; June 18 Sp. Sess. P.A. 97-8 added new Subsec. (i) to prohibit the limitation or exclusion of benefits based on preexisting conditions, effective July 1, 1997; June 30 Sp. Sess. P.A. 03-6 added Subsec. (j) re limitation or exclusion of benefit based on preexisting condition in comprehensive health care plans issued to health care tax credit eligible individuals, effective August 20, 2003; P.A. 04-10 changed "policy" to "plan" in Subsec. (j); P.A. 05-271 added new Subsec. (k) re preexisting conditions for members or dependents newly insured on or after October 1, 2005, and defining "qualifying coverage".

      See Sec. 38a-504 re insurance policy or contract requirements covering surgical removal of tumors and treatment of leukemia.

      Annotations to former section 38-373:

      Subsec. (c):

      Subdiv. (1)(B) cited. 186 C. 507.

      Subdiv. (1)(B) cited. 36 CS 561.