SubTitle38a-513-1_38a-513-14. Group Specified Disease Health Insurance Minimum Standards, Title38a Insurance Department, Regulations of Connecticut State Agencies

Regulations of Connecticut State Agencies (Last Updated: June 14,2023)

SubTitle38a-513-1_38a-513-14. Group Specified Disease Health Insurance Minimum Standards

Sec. 38a-513-1. Definitions

Latest version.

As used in sections 38a-513-1 to 38a-513-13, inclusive, of the Regulations of Connecticut State Agencies, unless otherwise provided:

(1) "Activities of daily living" means activities such as bathing, dressing, eating, toileting, and transferring.

(2) “Commissioner” means the Insurance Commissioner of the State of Connecticut.

(3) “Department” means the Connecticut Insurance Department.

(4) “Excessive rate” means the rate is unreasonably high for the insurance provided.

(5) “Experience period” means the most recent twelve (12) month period from which the insurer accumulates the data to support a rate filing.

(6) “Form” means a policy or certificate of insurance against loss or expense from sickness, or from bodily injury or death by accident, or application, rider or endorsement used in connection therewith.

(7) "Formulary" means a list of prescription drugs that are covered by a specific health insurance plan.

(8) "Group specified disease policy" means a group health insurance plan or certificate delivered or issued for delivery in this state which pays benefits for the diagnosis or treatment of one or more specifically named diseases, conditions or syndromes in accordance with section 38a-513-4(g)(13) of the Regulations of Connecticut State Agencies.

(9) “Health insurance plan” has the same meaning as provided in Section 38a-564 of the Connecticut General Statutes.

(10) “Inadequate rate” means a rate that is unreasonably low for the insurance provided, and continued use of it would endanger solvency of the insurer.

(11) "Insurer" means a health care center, as defined in Section 38a-175 of the Connecticut General Statutes, or an insurance company licensed by the Commissioner to write accident and health insurance.

(12) “Loss ratio” has the same meaning as provided in Section 38a-481(a) of the Connecticut General Statutes.

(13) "One period of confinement" means consecutive days of in-hospital service received as an in-patient, or successive confinements when discharge from and readmission to the hospital occurs within a period of not more than ninety (90) days or three times the maximum number of days of in-hospital coverage provided by the policy to a maximum of one hundred and eighty (180) days.

(14) "Pharmaceutical and therapeutics committee" or "P&T committee" means a group of members that may include physicians, pharmacists, administrators, quality improvement managers, other health care professionals and staff appointed by an insurer to establish policies regarding the use of drugs, therapies and drug-related products, identifying those that are most medically appropriate and cost effective.

(15) “PPACA” means Patient Protection and Affordable Care Act, P.L. 111-148, as amended from time to time, and regulations adopted thereunder.

(16) "Prescription drug tier" means a subset of the drugs covered in a formulary that are covered and subject to a specified level of cost share.

(17) “SERFF” means the National Association of Insurance Commissioners’ System for Electronic Rate and Form Filing.

(18) “Small employer” has the same meaning as provided in Section 38a-564 of the Connecticut General Statutes.

(19) "Specialty drug” means a unique prescription drug that may require special handling, close monitoring or may only be available from limited pharmacies.

(20) “Unfairly discriminatory” means rating practices that reflect differences based on age, disability, race, ethnicity, gender, sexual orientation or health status that are not actuarially justified or are otherwise prohibited by law.

(21) “Utilization data” means the number of services used by a fixed number of covered persons, as defined in Section 38a-591a of the Connecticut General Statutes, over a fixed length of time.

(Adopted effective November 30, 2009; Amended December 3, 2018)

Sec. 38a-513-2. Group health prohibited policy provisions

Latest version.

(a) Except as provided in section 38a-513-4(g)(4), no policy or certificate shall contain provisions establishing a probationary or waiting period during which no coverage is provided under the policy or certificate except the policy or certificate may specify a probationary or waiting period not to exceed six (6) months for specified diseases or conditions and losses resulting therefrom for hernia, disorder of reproductive organs, varicose veins, adenoids, appendix and tonsils. However, the permissible six (6) months exception shall not be applicable where such specified diseases or conditions are treated on an emergency basis. Accident policies shall not contain probationary or waiting periods.

(b) No policy or certificate shall exclude coverage for a loss due to a pre-existing condition for a period greater than twelve (12) months following policy issue where the application for such insurance does not seek disclosure of prior illness, disease or physical conditions or prior medical care and treatment.

(1) The insurance policy is non-cancellable or, if the benefit is added by rider, it is attached to a non-cancellable policy.

(2) The forms provide for the payment of surrender value upon:

(A) The written request of the insured, and surrender of the policy or certificate,

(B) Lapse of the policy or certificate,

(D) On the termination date of the contract.

(3) The surrender value is based on policy duration, premiums paid by the insured and benefits paid by the company and a refund is available after a certificate has been in force for a minimum of three (3) years (two (2) years on certificates issued on insureds forty-six (46) to fifty (50) years old).

(4) The form is not issued beyond age fifty (50).

(5) The insurer includes a detailed statement of the method of computing the premium rates, the tables of cash value, and the estimated loss ratio.

(6) The insurer includes a demonstration of the fiscal integrity of the product and the company.

(7) The form is not on the basis of the ten (10) year roll-over concept.

(d) No other policy or certificate shall provide a return of premium or cash value benefit, except returned or unearned premium upon termination or suspension of coverage, retroactive waiver of premium paid during disability, payment of dividends on participating policies, or experience rating refunds.

(e) Policies or certificates providing hospital confinement indemnity coverage shall not contain provisions excluding coverage because of confinement in a hospital operated by the federal government.

(f) No policy or certificate shall limit or exclude coverage by type of illness, accident, treatment or medical condition, except as follows:

(1) Pre-existing conditions or diseases where permitted, except for congenital anomalies of a covered dependent child;

(2) Mental or emotional disorders, alcoholism and drug addiction, except as set forth in section 38a-514 of the Connecticut General Statutes;

(3) Pregnancy, except for complications of pregnancy, other than for policies described in section 38a-513-4(c) of the Regulations of Connecticut State Agencies;

(4) Illness, treatment or medical condition arising out of:

(A) War or act of war (whether declared or undeclared); participation in a felony, riot or insurrections; service in the Armed Forces or units auxiliary thereto;

(B) Suicide (sane or insane), attempted suicide or intentionally self-inflicted injury;

(D) With respect to short-term renewable policies, inter-scholastic sports;

(5) Cosmetic surgery, except that cosmetic surgery shall not include reconstructive surgery when such service is incidental to or follows surgery resulting from trauma, infection or other diseases of the involved part, and reconstructive surgery because of congenital disease or anomaly of a covered dependent child that has resulted in a functional defect;

(6) Treatment provided in a government hospital, benefits provided under Medicare or other governmental program (except Medicaid), any state or federal workers' compensation, employers' liability or occupational disease law, or the basic reparations benefits of any motor vehicle no-fault law, services rendered by employees of hospitals, laboratories or other institutions, services performed by a member of the insured person's immediate family and services for which no charge is normally made in the absence of insurance;

(7) Dental care or treatment except as set forth in sections 38a-517, 38a-517a, and 38a-517b of the Connecticut General Statutes;

(8) Eye glasses, hearing aids and examination for the prescription or fitting thereof, except as set forth in section 38a-516b of the Connecticut General Statutes;

(9) Rest cures, custodial care, transportation and routine physical examinations; and

(10) Territorial limitations.

(g) Policy provisions precluded in this section shall not be construed as a limitation on the authority of the Commissioner to disapprove other policy provisions in accordance with section 38a-513 of the Connecticut General Statutes that, in the opinion of the Commissioner, are unjust, unfair, or deceptive, or unfairly discriminatory to the policyholder, beneficiary, or any person insured under the policy or that encourage misrepresentation of the policy.

(Effective December 3, 2018)

Sec. 38a-513-3. Minimum standards for group health insurance benefits

Latest version.

The following minimum standards for benefits are prescribed for the categories of coverage noted in subsections (a) to (g), inclusive, of this section. No such group policy or certificate shall be delivered or issued for delivery in this state that does not meet the required minimum standards for the specified categories unless the Commissioner finds that such policies or contracts are approvable as limited benefit health insurance. Nothing in this section shall preclude the issuance of any policy or contract combining two or more categories of coverage.

(a) General Rules.

(1) A "non-cancellable," "guaranteed renewable," or "non-cancellable and guaranteed renewable" policy shall not provide for termination of coverage of the spouse solely because of the occurrence of an event specified for termination of coverage of the insured, other than non-payment of premium. The policy shall provide that in the event of the insured's death the spouse of the insured, if covered under the policy, shall become the insured.

(2) The terms "non-cancellable," "guaranteed renewable," or "non-cancellable and guaranteed renewable" shall not be used without further explanation. The terms "non-cancellable" or "non-cancellable and guaranteed renewable" may be used only in a policy that the insured has the right to continue in force by the timely payment of premiums set forth in the policy until the age of sixty-five (65) or to eligibility for Medicare, during which period the insurer has no right to unilaterally make any change in any provision of the policy while the policy is in force. Any accident and health or accident only policy that provides for periodic payments, weekly or monthly, for a specified period during the continuance of disability resulting from accident or sickness may provide that the insured has the right to continue the policy only to age sixty (60) if, at age sixty (60), the insured has the right to continue the policy in force at least to age sixty-five (65) while actively or regularly employed. Except as provided above, the term "guaranteed renewable" may be used only in a policy that the insured has the right to continue in force by the timely payment of premiums until the age of sixty-five (65) or to eligibility for Medicare, during which period the insurer has no right to unilaterally make any change in any provision of the policy while the policy is in force, except as mandated by statute and except that the insurer may make changes in premium rates by classes. Any accident and health or accident only policy that provides for periodic payments, weekly or monthly, for a specified period during the continuance of disability resulting from accident or sickness may provide that the insured has the right to continue the policy only to age sixty (60) if at age sixty (60), the insured has the right to continue the policy in force at least to age sixty-five (65) while actively and regularly employed.

(3) If a policy contains a status type military service exclusion or a provision that suspends coverage during military service, the policy shall provide, upon receipt of written request, for refund of premiums as applicable to such person on a pro rata basis.

(4) In the event an insurer cancels or refuses to renew, policies providing pregnancy benefits shall provide for an extension of benefits as to a pregnancy that commences while the policy is in force and for which benefits would have been payable had the policy remained in force.

(5) Policies providing convalescent or extended care benefit following hospitalization shall not condition such benefits upon admission to the convalescent or extended care facility within a period of less than fourteen (14) days after discharge from the hospital.

(6) Family coverage shall continue for any dependent child who is incapable of self-sustaining employment due to mental or physical handicap on the date that such child's coverage would otherwise terminate under the policy due to the attainment of a specified age limit for children and is chiefly dependent on the insured for support and maintenance. The policy may require that within thirty-one (31) days of such date the company receive due proof of such incapacity in order for the insured to elect to continue the policy in force with respect to such child, or that a separate converted policy be issued at the option of the insured or policyholder.

(7) Any policy providing coverage for the recipient in a transplant operation shall also provide reimbursement of any medical expenses of a live donor to the extent that benefits remain and are available under the recipient's policy, after benefits for the recipient's own expenses have been paid.

(8) A policy may contain a provision relating to recurrent disabilities, except that no such provision shall specify that a recurrent disability be separated by a period of greater than six (6) months.

(9) Accidental death and dismemberment benefits shall be payable if the loss occurs within ninety (90) days after the date of the accident, irrespective of total disability. Disability income benefits, if provided, shall not require the loss to commence less than thirty (30) days after the date of accident, nor shall any policy that the insurer cancels or refuses to renew require that it be in force at the time disability commences if the accident occurred while the policy was in force.

(10) Specific dismemberment benefits shall not be in lieu of other benefits unless the specific benefit equals or exceeds the other benefits.

(11) Any accident only policy providing benefits that vary according to the type of accidental cause shall prominently describe the circumstances under which benefits are payable that are lesser than the maximum amount payable under the policy.

(12) Termination of the policy shall be without prejudice to any continuous loss that commenced while the policy was in force, but the extension of benefits beyond the period the policy was in force may be predicated upon the continuous total disability of the insured, limited to the duration of the policy benefit period, if any, or payment of the maximum benefits.

(b) "Hospital Confinement Indemnity Coverage" is a policy or certificate that provides daily benefits for hospital confinement on an indemnity basis in an amount not less than thirty dollars ($30) per day and not less than thirty-one (31) days during any one period of confinement for each person insured under the policy.

(c) "Disability Income Protection Coverage" is a policy or certificate that provides for periodic payments, weekly or monthly, for a specified period during the continuance of disability resulting from either sickness or injury or a combination thereof that:

(1) Provides that periodic payments that are payable at ages after age sixty-two (62) and reduced solely on the basis of age are at least fifty percent (50%) of amounts payable immediately prior to age sixty-two (62).

(2) Contains an elimination period no greater than:

(A) Ninety (90) days in the case of a coverage providing a benefit period of one (1) year or less;

(B) One hundred and eighty (180) days in the case of coverage providing a benefit of more than one (1) year but not greater than two (2) years, or

(C) Three hundred and sixty-five (365) days in all other cases during the continuance of disability resulting from sickness or injury.

(3) Has a maximum period of time for which it is payable during disability of at least six (6) months except in the case of a policy covering disability arising out of pregnancy, childbirth, or miscarriage in which case the period for such disability may be one (1) month. No reduction in benefits shall be put into effect because of an increase in Social Security or similar benefits during a benefit period. This section does not apply to those policies providing business buyout coverage.

(d) "Accident Only Coverage" is a policy or certificate that provides coverage, singly or in combination, for death, dismemberment, disability, or hospital and medical care caused by accident. Accidental death and double dismemberment amounts under such a policy shall be at least one thousand dollars ($1,000) and a single dismemberment amount shall be at least five hundred dollars ($500).

(e) "Specified Accident Coverage" is a policy or certificate that provides coverage for a specifically identified kind of accident (or accidents) for each person insured under the policy for accidental death or accidental death and dismemberment combined, with a benefit amount not less than one thousand dollars ($1,000) for accidental death; one thousand dollars ($1,000) for double dismemberment and five hundred dollars ($500) for single dismemberment.

(f) "Limited Benefit Health Insurance Coverage" is any policy or certificate that covers all of the minimum standards of a category of the type specified in subdivisions (1), (2), (3), (4), (5), (6), and (8) of section 38a-469 of the Connecticut General Statutes but at a lower level of coverage.

(g) “Specified Disease Coverage” is a policy or certificate delivered or issued for delivery in this state that pays benefits for the diagnosis or treatment of one or more specifically named diseases, conditions or syndromes in accordance with section 38a-513-4(g)(13) of the Regulations of Connecticut State Agencies.

(h) "Accident," "Accidental Injury," or "Accidental Means" shall be defined to employ "result" language and shall not include words that establish an accidental means test or use words such as "external, violent, visible wounds" or similar words of description or characterization. The definition shall not be more restrictive than the following: Injury or injuries, for which benefits are provided, means accidental bodily injuries sustained by the insured person that are the direct cause, independent of disease or bodily infirmity or any other cause and occur while the insurance is in force. Such definition may provide that injuries shall not include injuries for which benefits are provided under any workers' compensation, employers' liability or similar law, the basic reparations benefits of any motor vehicle no-fault plan or injuries occurring while the insured person is engaged in any activity pertaining to any trade, business, employment, or occupation for wage or profit.

(i) "Condition" includes specifically named diseases, conditions or syndromes unless the context otherwise requires.

(j) "Convalescent Nursing Home," "Extended Care Facility," or "Skilled Nursing Facility" shall be defined in relation to its status, facilities, and available services.

(1) A definition of such home or facility shall not be more restrictive than one requiring that it:

(A) Be operated pursuant to law;

(B) Be approved for payment of Medicare benefits or be qualified to receive such approval, if so requested;

(C) Be primarily engaged in providing, in addition to room and board accommodations, skilled nursing care under the supervision of a duly licensed physician;

(D) Provide continuous twenty-four (24) hours a day nursing service by or under the supervision of a registered nurse;

(E) Maintain a daily medical record of each patient.

(2) The definition of such home or facility may provide that such term shall not be inclusive of:

(A) Any home, facility or part thereof used primarily for rest;

(B) A home or facility for the aged or for the care of drug addicts or alcoholics; or

(C) A home or facility primarily used for the care and treatment of mental diseases or disorders or custodial or educational care.

(k) "Hospital" may be defined in relation to its status, facilities and available services or to reflect its accreditation by the Joint Commission on Accreditation of Hospitals.

(1) The definition of the term "hospital" shall not be more restrictive than one requiring that the hospital:

(A) Be an institution operated pursuant to law; and

(B) Be primarily and continuously engaged in providing or operating either on its premises or in facilities available to the hospital on a prearranged basis and under the supervision of a staff of duly licensed physicians, medical, diagnostic and major surgical facilities for the medical care and treatment of sick or injured persons on an in-patient basis for which a charge is made; and

(2) The definition of the term "hospital" may state that such term shall not be inclusive of:

(A) Convalescent homes, convalescent, rest, or nursing facilities; or

(B) Facilities primarily affording custodial, educational or rehabilitative care; or

(D) Any military or veterans’ hospital or soldiers' home or any hospital contracted for or operated by any national government or agency thereof for the treatment of members or former members of the Armed Forces, except for services rendered on an emergency basis where a legal liability exists for charges made to the individual for such services.

(l) "Medicare" shall be defined in any hospital, surgical or medical expense policy that relates its coverage to eligibility for Medicare or Medicare benefits. Medicare may be substantially defined as "The Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965 as Then Constituted or Later Amended," or "Title I, Part I of Public Law 89-97, as Enacted by the Eighty-Ninth Congress of the United States of America and popularly known as the Health Insurance for the Aged Act, as then constituted and any later amendments or substitutes thereof" or words of similar import.

(m) "Nurses" may be defined so that the description of nurse is restricted to a type of nurse, such as registered nurse or licensed practical nurse. If the words "nurse," "trained nurse" or "registered nurse" are used without specific instruction, then the use of such terms requires the insurer to recognize the services of any individual who qualifies under such terminology in accordance with the applicable statutes or administrative rules of the licensing or registry board of the state.

(n) "Partial Disability" shall be defined in relation to the individual's inability to perform one or more, but not all, of the "major," "important," or "essential" duties of his employment or occupation or may be related to a "percentage" of time worked or to a "specified number of hours" or to "compensation." Where a policy provides total disability benefits and partial disability benefits, only one (1) elimination period may be required.

(o) "Physician" shall be defined as a person who is licensed by the state in which he or she practices to give treatment for which benefits are provided under the policy and who is acting within the scope of his or her license.

(p) "Pre-existing condition" shall not be defined to be more restrictive than the following: Pre-existing condition means the existence of symptoms that would cause an ordinarily prudent person to seek diagnosis, care or treatment within a five (5) year period preceding the effective date of the coverage of the insured person or a condition for which medical advice or treatment was recommended by a physician or received from a physician within a five (5) year period preceding the effective date of the coverage of the insured person. This definition does not prohibit an insurer, using an application form designated to elicit the complete health history of a prospective insured and on the basis of the answers on that application, from underwriting in accordance with that insurer's established standards. It is assumed that an insurer that elicits a complete health history of a prospective insured will act on the information and if the review of the health history results in a decision to exclude a condition, the policy will be endorsed or amended by including the specific exclusion. This same requirement of notice to the prospective insured of the specific exclusion will also apply to insurers that elect to use simplified application forms containing questions relating to the prospective insured's health. This definition does, however, prohibit an insurer that elects to use a simplified application, with or without a question as to the applicant's health at the time of application, from reducing or denying a claim on the basis of the existence of a pre-existing condition that is defined more restrictively than above.

(q) "Residual Disability" shall be defined in relation to the individual's reduction in earnings and may be related either to the inability to perform some part of the "major," "important," or "essential duties" of employment or occupation, or to the inability to perform all usual business duties for as long as is usually required. A policy that provides for residual disability benefits may require a qualification period, during which the insured person must be continuously totally disabled before residual disability benefits are payable. The qualification period for residual benefits may be longer than the elimination period for total disability. In lieu of the term "residual disability," the insurer may use "proportionate disability" or other term of similar import that in the opinion of the commissioner adequately and fairly describes the benefit.

(r) "Sickness" shall not be defined to be more restrictive than the following: Sickness means sickness or disease of an insured person that first manifests itself after the effective date of insurance and while the insurance is in force. A definition of sickness may provide for a probationary period that shall not exceed thirty (30) days from the effective date of the coverage of the insured person. The definition may be further modified to exclude sickness or disease for which benefits are provided under any workers' compensation, occupational disease, employer's liability or similar law.

(s) (1) "Total Disability" shall not be defined more restrictively than to mean an individual who is (A) totally disabled from engaging in any employment or occupation for which such individual is, or becomes, qualified by reason of education, training or experience, and (B) not engaged in any employment or occupation for wage or profit.

(2) "Total disability" may be defined in relation to the inability of an individual to perform duties, but may not be based solely upon an individual's inability to (A) perform any occupation whatsoever, any occupational duty, or any and every duty of such individual's occupation, or (B) engage in any training or rehabilitation program. An insurer may require that an individual be completely unable to perform all of the substantial and material duties of such individual's regular occupation to be totally disabled, and may require that an individual receive care from a physician who is not the insured or a member of the insured's immediate family.

(Effective December 3, 2018)

Sec. 38a-513-4. Required provisions for group health insurance benefits

Latest version.

(a) General Rules.

(1) Each group policy or certificate of accident and sickness insurance shall include a renewal, continuation, or non-renewal provision. The language or specifications of such provision shall be consistent with the type of contract to be issued. Such provision shall be appropriately captioned, shall appear on the first page of the policy, and shall clearly state the duration, where limited, of renewability and the duration of the term of coverage for which the policy is issued and for which it may be renewed.

(2) Except for riders or endorsements by which the insurer effectuates a request made in writing by the policyholder, or exercises a specifically reserved right under the policy or certificate, all riders or endorsements added to a policy or certificate after date of issue or at reinstatement or renewal that reduce or eliminate benefits or coverage in the policy or certificate shall require signed acceptance by the policyholder. After the date of policy or certificate issue, any rider or endorsement that increases benefits or coverage with a concomitant increase in premium during the policy term shall be agreed to in writing signed by the policyholder, except if the increase in benefit or coverage is required by law.

(3) Where a separate additional premium is charged for benefits provided in connection with riders or endorsements, such premium charge shall be set forth in the policy or certificate.

(4) A policy or certificate that provides for the payment of benefits based on standards described as "usual and customary," "reasonable and customary," “maximum allowable charge,” or words of similar import shall include a definition of such terms and an explanation of such terms.

(5) If a policy or certificate contains any limitations with respect to pre-existing conditions, such limitations shall appear as a separate paragraph of the policy or certificate and be labeled as "Pre-existing Conditions Limitations."

(6) All accident only policies shall contain a prominent statement on the first page or an attachment to the policy and certificate in either contrasting color or in boldface type at least equal to the size of type used for policy captions, a prominent statement as follows: "This is an accident only policy and it does not pay benefits for loss from sickness."

(7) If a policy contains a conversion privilege, it shall comply, in substance, with the following: The caption of the provision shall be "Conversion Privilege" or words of similar import. The provision shall indicate the persons eligible for conversion, the circumstances applicable to the conversion privilege, including any limitations on the conversion, and the person by whom the conversion privilege may be exercised. The provision shall specify the benefits to be provided on conversion or may state that the converted coverage will be as provided on a policy form then being used by the insurer for that purpose.

(b) Hospital confinement indemnity policies or certificates are designed to provide, to persons insured, coverage in the form of a fixed daily benefit during periods of hospitalization resulting from a covered accident or sickness, subject to any limitations set forth in the policy. Such policies do not provide any benefits other than the fixed daily indemnity for hospital confinement and any additional benefits that are described pursuant to subdivision (4) of this subsection. The policy or certificate shall include:

(1) A clear and concise description of the benefits including a description of any deductible, coinsurance or co-payment provisions applicable to the benefits described, and proper disclosure of benefits that vary according to accidental cause and also including:

(A) Daily benefit payable during hospital confinement; and

(B) Duration of the benefit described in subparagraph (A) of this subdivision.

(2) A description of any policy provisions that exclude, eliminate, restrict, reduce, limit, delay, or in any other manner operate to qualify payment of the benefits described pursuant to subdivision (1) of this subsection.