Conn. Gen. Stat. § 38a-488b — Connecticut Code / Title 38a / Chapter 700c / Section 38a-488b
Sec. 38a-488b. Coverage for autism spectrum disorder therapies.
Status: in_force

(1) “Applied behavior analysis” means the design, implementation and evaluation of environmental modifications, using behavioral stimuli and consequences, including the use of direct observation, measurement and functional analysis of the relationship between environment and behavior, to produce socially significant improvement in human behavior.

(2) “Autism spectrum disorder services provider” means any person, entity or group that provides treatment for an autism spectrum disorder pursuant to this section.

(3) “Autism spectrum disorder” means “autism spectrum disorder” as set forth in the most recent edition of the American Psychiatric Association's “Diagnostic and Statistical Manual of Mental Disorders”.

(4) “Behavioral therapy” means any interactive behavioral therapies derived from evidence-based research and consistent with the services and interventions designated by the Commissioner of Social Services pursuant to subsection (e) of section 17a-215c , including, but not limited to, applied behavior analysis, cognitive behavioral therapy, or other therapies supported by empirical evidence of the effective treatment of individuals diagnosed with autism spectrum disorder, that are: (A) Provided to children less than twenty-one years of age; and (B) provided or supervised by (i) a licensed behavior analyst, (ii) a licensed physician, or (iii) a licensed psychologist. For the purposes of this subdivision, behavioral therapy is “supervised by” such licensed behavior analyst, licensed physician or licensed psychologist when such supervision entails at least one hour of face-to-face supervision of the autism spectrum disorder services provider by such licensed behavior analyst, licensed physician or licensed psychologist for each ten hours of behavioral therapy provided by the supervised provider.

(5) “Diagnosis” means the medically necessary assessment, evaluation or testing performed by a licensed physician, licensed psychologist or licensed clinical social worker to determine if an individual has autism spectrum disorder.

(b) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 that is delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for the diagnosis and treatment of autism spectrum disorder. For the purposes of this section and section 38a-482a , autism spectrum disorder shall be considered an illness.

(c) Such policy shall provide coverage for the following treatments, provided such treatments are (1) medically necessary, and (2) identified and ordered by a licensed physician, licensed psychologist or licensed clinical social worker for an insured who is diagnosed with autism spectrum disorder, in accordance with a treatment plan developed by a licensed behavior analyst, licensed physician, licensed psychologist or licensed clinical social worker, pursuant to a comprehensive evaluation or reevaluation of the insured:

(A) Behavioral therapy;

(B) Prescription drugs, to the extent prescription drugs are a covered benefit for other diseases and conditions under such policy, prescribed by a licensed physician, a licensed physician assistant or an advanced practice registered nurse for the treatment of symptoms and comorbidities of autism spectrum disorder;

(C) Direct psychiatric or consultative services provided by a licensed psychiatrist;

(D) Direct psychological or consultative services provided by a licensed psychologist;

(E) Physical therapy provided by a licensed physical therapist;

(F) Speech and language pathology services provided by a licensed speech and language pathologist; and

(G) Occupational therapy provided by a licensed occupational therapist.

(d) Such policy shall not impose (1) any limits on the number of visits an insured may make to an autism spectrum disorder services provider pursuant to a treatment plan on any basis other than a lack of medical necessity, or (2) a coinsurance, copayment, deductible or other out-of-pocket expense for such coverage that places a greater financial burden on an insured for access to the diagnosis and treatment of autism spectrum disorder than for the diagnosis and treatment of any other medical, surgical or physical health condition under such policy.

(e) (1) Except for treatments and services received by an insured in an inpatient setting, an insurer, health care center, hospital service corporation, medical service corporation or fraternal benefit society may review a treatment plan developed as set forth in subsection (c) of this section for such insured, in accordance with its utilization review requirements, not more than once every six months unless such insured's licensed physician, licensed psychologist or licensed clinical social worker agrees that a more frequent review is necessary or changes such insured's treatment plan.

(2) For the purposes of this section, the results of a diagnosis shall be valid for a period of not less than twelve months, unless such insured's licensed physician, licensed psychologist or licensed clinical social worker determines a shorter period is appropriate or changes the results of such insured's diagnosis.

(f) Coverage required under this section may be subject to the other general exclusions and limitations of the individual health insurance policy, including, but not limited to, coordination of benefits, participating provider requirements, restrictions on services provided by family or household members and case management provisions, except that any utilization review shall be performed in accordance with subsection (e) of this section.

(g) (1) Nothing in this section shall be construed to limit or affect (A) any other covered benefits available to an insured under (i) such individual health insurance policy, (ii) section 38a-488a , or (iii) section 38a-490a , (B) any obligation to provide services to an individual under an individualized education program pursuant to section 10-76d , or (C) any obligation imposed on a public school by the Individual With Disabilities Education Act, 20 USC 1400 et seq., as amended from time to time.

(2) Nothing in this section shall be construed to require such individual health insurance policy to provide reimbursement for special education and related services provided to an insured pursuant to section 10-76d , unless otherwise required by state or federal law.

See Sec. 38a-514b for provisions re group policies.
Conn. Gen. Stat. § 38a-591d — Connecticut Code / Title 38a / Chapter 700c / Section 38a-591d
Sec. 38a-591d. Utilization review and benefit determinations. Urgent care requests. Information provided in notice of adverse determination.
Status: in_force

(2) In determining whether a benefit request shall be considered an urgent care request, an individual acting on behalf of a health carrier shall apply the judgment of a prudent layperson who possesses an average knowledge of health and medicine, except that any benefit request (A) determined to be an urgent care request by a health care professional with knowledge of the covered person's medical condition, or (B) specified under subparagraph (B) or (C) of subdivision (38) of section 38a-591a shall be deemed an urgent care request.

(3) (A) At the time a health carrier notifies a covered person, a covered person's authorized representative or a covered person's health care professional of an initial adverse determination that was based, in whole or in part, on medical necessity, of a concurrent or prospective utilization review or of a benefit request, the health carrier shall notify the covered person's health care professional (i) of the opportunity for a conference as provided in subparagraph (B) of this subdivision, and (ii) that such conference shall not be considered a grievance of such initial adverse determination as long as a grievance has not been filed as set forth in subparagraph (B) of this subdivision.

(B) After a health carrier notifies a covered person, a covered person's authorized representative or a covered person's health care professional of an initial adverse determination that was based, in whole or in part, on medical necessity, of a concurrent or prospective utilization review or of a benefit request, the health carrier shall offer a covered person's health care professional the opportunity to confer, at the request of the covered person's health care professional, with a clinical peer of such health carrier, provided such covered person, covered person's authorized representative or covered person's health care professional has not filed a grievance of such initial adverse determination prior to such conference. Such conference shall not be considered a grievance of such initial adverse determination. Such health carrier shall grant such clinical peer the authority to reverse such initial adverse determination.

(b) With respect to a nonurgent care request:

(1) (A) For a prospective or concurrent review request, a health carrier shall make a determination within a reasonable period of time appropriate to the covered person's medical condition, but not later than seven calendar days after the date the health carrier receives such request, and shall notify the covered person and, if applicable, the covered person's authorized representative of such determination, whether or not the carrier certifies the provision of the benefit.

(B) If the review under subparagraph (A) of this subdivision is a review of a grievance involving a concurrent review request, pursuant to 45 CFR 147.136, as amended from time to time, the treatment shall be continued without liability to the covered person until the covered person has been notified of the review decision.

(2) For a retrospective review request, a health carrier shall make a determination within a reasonable period of time, but not later than thirty calendar days after the date the health carrier receives such request.

(3) (A) The time period specified in subdivision (1) of this subsection may be extended once by the health carrier for up to five calendar days, and the time period specified in subdivision (2) of this subsection may be extended once by the health carrier for up to fifteen calendar days, provided the health carrier:

(i) Determines that an extension is necessary due to circumstances beyond the health carrier's control; and

(ii) Notifies the covered person and, if applicable, the covered person's authorized representative prior to the expiration of the initial time period, of the circumstances requiring the extension of time and the date by which the health carrier expects to make a determination.

(B) Notwithstanding the provisions of subparagraph (A) of subdivision (3) of this subsection, the time period specified in subdivision (1) of this subsection may be extended once by the health carrier for up to fifteen calendar days, provided the covered person's health care professional notifies the health carrier that the service will not be performed for at least three months from the date such health carrier received the request.

(4) (A) If the extension pursuant to subdivision (3) of this subsection is necessary due to the failure of the covered person or the covered person's authorized representative to provide information necessary to make a determination on the request, the health carrier shall:

(i) Specifically describe in the notice of extension the required information necessary to complete the request; and

(ii) Provide the covered person and, if applicable, the covered person's authorized representative with not less than forty-five calendar days after the date of receipt of the notice to provide the specified information.

(B) If the covered person or the covered person's authorized representative fails to submit the specified information before the end of the period of the extension, the health carrier may deny certification of the benefit requested.

(c) With respect to an urgent care request:

(1) (A) Unless the covered person or the covered person's authorized representative has failed to provide information necessary for the health carrier to make a determination and except as specified under subparagraph (B) of this subdivision, the health carrier shall make a determination as soon as possible, taking into account the covered person's medical condition, but not later than twenty-four hours after the health carrier receives such request, provided, if the urgent care request is a concurrent review request to extend a course of treatment beyond the initial period of time or the number of treatments, such request is made not less than twenty-four hours prior to the expiration of the prescribed period of time or number of treatments.

(B) Unless the covered person or the covered person's authorized representative has failed to provide information necessary for the health carrier to make a determination, for an urgent care request specified under subparagraph (B) or (C) of subdivision (38) of section 38a-591a , the health carrier shall make a determination as soon as possible, taking into account the covered person's medical condition, but not later than twenty-four hours after the health carrier receives such request, provided, if the urgent care request is a concurrent review request to extend a course of treatment beyond the initial period of time or the number of treatments, such request is made not less than twenty-four hours prior to the expiration of the prescribed period of time or number of treatments.

(2) (A) If the covered person or the covered person's authorized representative has failed to provide information necessary for the health carrier to make a determination, the health carrier shall notify the covered person or the covered person's representative, as applicable, as soon as possible, but not later than twenty-four hours after the health carrier receives such request.

(B) The health carrier shall provide the covered person or the covered person's authorized representative, as applicable, a reasonable period of time to submit the specified information, taking into account the covered person's medical condition, but not less than forty-eight hours after notifying the covered person or the covered person's authorized representative, as applicable.

(3) The health carrier shall notify the covered person and, if applicable, the covered person's authorized representative of its determination as soon as possible, but not later than forty-eight hours after the earlier of (A) the date on which the covered person and the covered person's authorized representative, as applicable, provides the specified information to the health carrier, or (B) the date on which the specified information was to have been submitted.

(d) (1) Whenever a health carrier receives a review request from a covered person or a covered person's authorized representative that fails to meet the health carrier's filing procedures, the health carrier shall notify the covered person and, if applicable, the covered person's authorized representative of such failure not later than five calendar days after the health carrier receives such request, except that for an urgent care request, the health carrier shall notify the covered person and, if applicable, the covered person's authorized representative of such failure not later than twenty-four hours after the health carrier receives such request. For a nonurgent prospective or concurrent review request, each health carrier shall acknowledge receipt of each such request as soon as practicable, but not later than twenty-four hours after the health carrier receives such request, except that such health carrier shall respond in less time if such a response is required by applicable federal law.

(2) If the health carrier provides such notice orally, the health carrier shall provide confirmation in writing to the covered person and the covered person's health care professional of record not later than three calendar days after providing the oral notice. No health carrier shall require a health care professional or hospital to submit additional information that was not reasonably available to such health care professional or hospital at the time that such health care professional or hospital filed the prospective or concurrent review request with such health carrier.

(e) Each health carrier shall provide promptly to a covered person and, if applicable, the covered person's authorized representative a notice of an adverse determination.

(1) Such notice may be provided in writing or by electronic means and shall set forth, in a manner calculated to be understood by the covered person or the covered person's authorized representative:

(A) Information sufficient to identify the benefit request or claim involved, including the date of service, if applicable, the health care professional and the claim amount;

(B) The specific reason or reasons for the adverse determination, including, upon request, a listing of the relevant clinical review criteria, including professional criteria and medical or scientific evidence and a description of the health carrier's standard, if any, that were used in reaching the denial;

(C) Reference to the specific health benefit plan provisions on which the determination is based;

(D) A description of any additional material or information necessary for the covered person to perfect the benefit request or claim, including an explanation of why the material or information is necessary to perfect the request or claim;

(E) A description of the health carrier's internal grievance process that includes (i) the health carrier's expedited review procedures, (ii) any time limits applicable to such process or procedures, (iii) the contact information for the organizational unit designated to coordinate the review on behalf of the health carrier, and (iv) a statement that the covered person or, if applicable, the covered person's authorized representative is entitled, pursuant to the requirements of the health carrier's internal grievance process, to receive from the health carrier, free of charge upon request, reasonable access to and copies of all documents, records, communications and other information and evidence regarding the covered person's benefit request;

(F) (i) (I) A copy of the specific rule, guideline, protocol or other similar criterion the health carrier relied upon to make the adverse determination, or (II) a statement that a specific rule, guideline, protocol or other similar criterion of the health carrier was relied upon to make the adverse determination and that a copy of such rule, guideline, protocol or other similar criterion will be provided to the covered person free of charge upon request, with instructions for requesting such copy, and (ii) the links to such rule, guideline, protocol or other similar criterion on such health carrier's Internet web site;

(G) If the adverse determination is based on medical necessity or an experimental or investigational treatment or similar exclusion or limit, the written statement of the scientific or clinical rationale for the adverse determination and (i) an explanation of the scientific or clinical rationale used to make the determination that applies the terms of the health benefit plan to the covered person's medical circumstances, or (ii) a statement that an explanation will be provided to the covered person free of charge upon request, and instructions for requesting a copy of such explanation;

(H) A statement explaining the right of the covered person to contact the commissioner's office or the Office of the Healthcare Advocate at any time for assistance or, upon completion of the health carrier's internal grievance process, to file a civil action in a court of competent jurisdiction. Such statement shall include the contact information for said offices; and

(I) A statement, expressed in language approved by the Healthcare Advocate and prominently displayed on the first page or cover sheet of the notice using a call-out box and large or bold text, that if the covered person or the covered person's authorized representative chooses to file a grievance of an adverse determination, (i) such appeals are sometimes successful, (ii) such covered person or covered person's authorized representative may benefit from free assistance from the Office of the Healthcare Advocate, which can assist such covered person or covered person's authorized representative with the filing of a grievance pursuant to 42 USC 300gg-93, as amended from time to time, (iii) such covered person or covered person's authorized representative is entitled and encouraged to submit supporting documentation for the health carrier's consideration during the review of an adverse determination, including narratives from such covered person or covered person's authorized representative and letters and treatment notes from such covered person's health care professional, and (iv) such covered person or covered person's authorized representative has the right to ask such covered person's health care professional for such letters or treatment notes.

(2) Upon request pursuant to subparagraph (E) of subdivision (1) of this subsection, the health carrier shall provide such copies in accordance with subsection (a) of section 38a-591n .

(f) If the adverse determination is a rescission, the health carrier shall include with the advance notice of the application for rescission required to be sent to the covered person, a written statement that includes:

(1) Clear identification of the alleged fraudulent act, practice or omission or the intentional misrepresentation of material fact;

(2) An explanation as to why the act, practice or omission was fraudulent or was an intentional misrepresentation of a material fact;

(3) A disclosure that the covered person or the covered person's authorized representative may file immediately, without waiting for the date such advance notice of the proposed rescission ends, a grievance with the health carrier to request a review of the adverse determination to rescind coverage, pursuant to sections 38a-591e and 38a-591f ;

(4) A description of the health carrier's grievance procedures established under sections 38a-591e and 38a-591f , including any time limits applicable to those procedures; and

(5) The date such advance notice of the proposed rescission ends and the date back to which the coverage will be retroactively rescinded.

(g) (1) Whenever a health carrier fails to strictly adhere to the requirements of this section with respect to making utilization review and benefit determinations of a benefit request or claim, the covered person shall be deemed to have exhausted the internal grievance process of such health carrier and may file a request for an external review in accordance with the provisions of section 38a-591g , regardless of whether the health carrier asserts it substantially complied with the requirements of this section or that any error it committed was de minimis.

(2) A covered person who has exhausted the internal grievance process of a health carrier may, in addition to filing a request for an external review, pursue any available remedies under state or federal law on the basis that the health carrier failed to provide a reasonable internal grievance process that would yield a decision on the merits of the claim.
Conn. Gen. Stat. § 38a-91pp — Connecticut Code / Title 38a / Chapter 698 / Section 38a-91pp
Sec. 38a-91pp. Conversions and mergers. Approval by commissioner.
Status: in_force

(b) Any plan for such conversion or merger shall provide a fair and equitable plan for purchasing, retiring or otherwise extinguishing the interests of the stockholders and policyholders of a stock insurer, and the members and policyholders of a mutual corporation, including a fair and equitable provision for the rights and remedies of dissenting stockholders, members or policyholders.

(c) In the case of a conversion authorized under subsection (a) of this section:

(1) Such conversion shall be accomplished under such reasonable plan and procedure as may be approved by the commissioner, except that the Insurance Commissioner shall not approve any such plan of conversion unless such plan:

(A) Satisfies the provisions of subsection (b) of this section;

(B) Provides for a hearing, of which notice is given or to be given to the captive insurance company, its directors, officers and policyholders, and in the case of a stock insurer, its stockholders, and in the case of a mutual corporation, its members, all of which persons shall be entitled to attend and appear at such hearing, except that if notice of a hearing is given and no director, officer, policyholder, member or stockholder requests a hearing, the commissioner may cancel such hearing;

(C) Provides a fair and equitable plan for the conversion of stockholder, member or policyholder interests into subscriber interests in the resulting reciprocal insurer, substantially proportionate to the corresponding interests in the stock insurer or mutual corporation, except that such plan shall not preclude the resulting reciprocal insurer from applying underwriting criteria that could affect ongoing ownership interests; and

(D) Is approved:

(i) In the case of a stock insurer, by a majority of the shares entitled to vote represented in person or by proxy at a duly called regular or special meeting at which a quorum is present; and

(ii) In the case of a mutual corporation, by a majority of the voting interests of policyholders represented in person or by proxy at a duly called regular or special meeting thereof at which a quorum is present;

(2) The commissioner shall approve such plan of conversion if the commissioner finds that the conversion will promote the general good of the state in conformity with those standards set forth in subdivision (2) of subsection (g) of section 38a-91ff ;

(3) If the commissioner approves the plan, the commissioner shall amend the converting insurer's certificate of authority to reflect conversion to a reciprocal insurer and issue such amended certificate of authority to the company's attorney-in-fact;

(4) The conversion shall be effective upon the issuance of an amended certificate of authority of a reciprocal insurer by the commissioner; and

(5) Upon the effective date of such conversion the corporate existence of the converting insurer shall cease and the resulting reciprocal insurer shall notify the Secretary of the State of such conversion.

(d) A merger authorized under subsection (a) of this section shall be accomplished substantially in accordance with the procedures set forth in this chapter, except that, solely for purposes of such merger:

(1) The plan of merger shall satisfy the provisions of subsection (b) of this section;

(2) The subscribers' advisory committee of a reciprocal insurer shall be equivalent to the board of directors of a stock insurer or mutual corporation;

(3) The subscribers of a reciprocal insurer shall be the equivalent of the policyholders of a mutual corporation;

(4) If a subscribers' advisory committee does not have a president or secretary, the officers of such committee having substantially equivalent duties shall be deemed the president or secretary of such committee;

(5) The commissioner shall approve the articles of merger if the commissioner finds that the merger will promote the general good of the state in conformity with those standards set forth in subdivision (2) of subsection (g) of section 38a-91ff . If the commissioner approves the articles of merger, the commissioner shall endorse the commissioner's approval thereon and the surviving insurer shall present the articles of merger to the Secretary of the State at the Secretary of the State's office;

(6) Notwithstanding section 38a-91dd , the commissioner may permit the formation, without surplus, of a captive insurance company organized as a reciprocal insurer, into which an existing captive insurance company may be merged for the purpose of facilitating a transaction under this section, except that there shall be no more than one authorized insurance company surviving such merger; and

(7) An alien insurer may be a party to a merger authorized under subsection (a) of this section, except that the requirements for a merger between a domestic and a foreign insurer under this chapter shall apply to a merger between a domestic and an alien insurer under this subsection. Such alien insurer shall be treated as a foreign insurer under this chapter and such other jurisdictions shall be the equivalent of a state for purposes of this chapter.

(e) The commissioner may permit the formation of a captive insurance company that is established for the sole purpose of merging or consolidating with, or assuming existing insurance or reinsurance business from, an existing captive insurance company or, subject to such conditions as the commissioner may impose that are not inconsistent with this chapter, any existing captive insurance company organized in any other jurisdiction. Upon request of such newly formed captive insurance company, the commissioner may waive or modify the requirements of subparagraph (B) of subdivision (1) of subsection (c) of section 38a-91bb , and subdivision (2) of subsection (c) of section 38a-91bb .

(f) A conversion or merger under this section shall have the effects of conversion or merger set forth in this chapter to the extent such effects are not inconsistent with the provisions of sections 38a-91aa to 38a-91tt , inclusive.
Conn. Gen. Stat. § 38a-477aa — Connecticut Code / Title 38a / Chapter 700c / Section 38a-477aa
Sec. 38a-477aa. Cost-sharing and health care provider reimbursements for emergency services, urgent crisis center services and surprise bills.
Status: in_force

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(c) With respect to a surprise bill:

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

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

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

(e) The provisions of this section shall apply to a high deductible health plan, as that term is used in subsection (f) of section 38a-493 or subsection (f) of section 38a-520 , as applicable, to the maximum extent permitted by federal law, except if such plan is used to establish a medical savings account or an Archer MSA pursuant to Section 220 of the Internal Revenue Code of 1986, or any subsequent corresponding internal revenue code of the United States, as amended from time to time, or a health savings account pursuant to Section 223 of said Internal Revenue Code, as amended from time to time, the provisions of this section shall apply to such plan to the maximum extent that (1) is permitted by federal law, and (2) does not disqualify such account for the deduction allowed under said Section 220 or 223, as applicable.
Conn. Gen. Stat. § 38a-825 — Connecticut Code / Title 38a / Chapter 704 / Section 38a-825
Sec. 38a-825. (Formerly Sec. 38-59). Premium rebate or other special favor. Permissible benefits for value-added products or services.
Status: in_force

(b) Except as provided in subsection (c) or (d) of this section:

(1) No insurance company doing business in this state, attorney, producer or any other person shall pay or allow, or offer to pay or allow, as inducement to insurance, any rebate of premium payable on the policy, or any special favor or advantage in the dividends or other benefits to accrue thereon, or any valuable consideration or inducement not specified in the policy of insurance; and

(2) No person shall:

(A) Receive or accept from any insurance company, attorney, producer or any other person, as inducement to insurance, any rebate of premium payable on the policy, or any special favor or advantage in the dividends or other benefits to accrue thereon, or any valuable consideration or inducement not specified in the policy of insurance; or

(B) Be excused from testifying or from producing any books, papers, contracts, agreements or documents, at the trial of any other person charged with the violation of any provision of this section or of section 38a-446 , on the ground that such testimony or evidence may tend to incriminate such person, provided such person shall not be prosecuted for any act concerning which such person is compelled to so testify or produce documentary or other evidence unless such prosecution is for perjury committed in so testifying.

(c) (1) An insurance company doing business in this state, attorney, producer or any other person may offer or provide to a customer in this state, at no cost or a reduced cost, a value-added product or service that is not specified in the customer's insurance policy if:

(A) Such value-added product or service:

(i) Relates to the insurance coverage provided under the customer's insurance policy; and

(ii) Is primarily designed to:

(I) Provide loss mitigation or loss control;

(II) Reduce claim costs or claim settlement costs;

(III) Provide education about liability risks or risk of loss to persons or property;

(IV) Monitor or assess risk, identify sources of risk or develop strategies for eliminating or reducing risk;

(V) Enhance health;

(VI) Enhance financial wellness through items including, but not limited to, education and financial planning services;

(VII) Provide post-loss services;

(VIII) Incentivize behavioral changes to improve the health, or reduce the risk of death or disability, of a customer; or

(IX) Assist in the administration of employee or retiree benefit insurance coverage;

(B) The cost to the insurance company, attorney, producer or other person offering or providing such value-added product or service for the customer is, in the opinion of the commissioner, reasonable in comparison to the customer's premiums or insurance coverage;

(C) The insurance company, attorney, producer or other person offering or providing such value-added product or service ensures that the customer receives contact information to assist the customer with questions regarding such value-added product or service;

(D) Such value-added product or service is offered and provided in a manner that, in the opinion of the commissioner, is not unfairly discriminatory; and

(E) The availability of such value-added product or service is based on documented and objective criteria, which the insurance company, attorney, producer or other person offering or providing such value-added product or service shall maintain and produce to the commissioner upon the commissioner's request for said criteria.

(2) If an insurance company doing business in this state, attorney, producer or other person does not have sufficient evidence to demonstrate to the commissioner that a value-added product or service satisfies the criteria established in subparagraph (A) of subdivision (1) of this subsection, but believes, in good faith, that the value-added product or service satisfies said criteria, the insurance company, attorney, producer or other person may offer and provide such value-added product or service to customers in this state as part of a pilot or testing program for not more than one year, provided:

(A) Such value-added product or service is offered and provided to customers in a manner that, in the opinion of the commissioner, is not unfairly discriminatory; and

(B) Such insurance company, attorney, producer or other person:

(i) Provides advance notice to the commissioner, in a form and manner prescribed by the commissioner, that such insurance company, attorney, producer or other person intends to commence such pilot or testing program; and

(ii) Shall not commence such pilot or testing program if the commissioner notifies such insurance company, attorney, producer or other person, in a form and manner prescribed by the commissioner and not later than twenty-one days after the commissioner receives notice pursuant to subparagraph (B)(i) of this subdivision, that the commissioner has determined such insurance company, attorney, producer or other person shall not commence such pilot or testing program.

(d) An insurance company doing business in this state, attorney, producer or any other person may offer or give a noncash gift, item or service to or on behalf of a customer:

(1) In connection with the marketing, sale, purchase or retention of a contract of insurance, provided:

(A) The cost of the noncash gift, item or service does not exceed an amount that the commissioner, in the commissioner's discretion, deems reasonable per policy year per term;

(B) The offer is made in a manner that, in the commissioner's opinion, is not unfairly discriminatory; and

(C) The customer is not required to purchase, continue to purchase or renew an insurance policy in exchange for the noncash gift, item or service; or

(2) To a commercial or institutional customer in connection with the marketing, purchase or retention of a contract of insurance, provided:

(A) The cost of the noncash gift, item or service is, in the commissioner's opinion, reasonable in comparison to the premium or proposed premium of the contract of insurance;

(B) The cost of the noncash gift, item or service is not included in any amount charged to another person;

(C) The offer is made in a manner that, in the commissioner's opinion, is not unfairly discriminatory; and

(D) The customer is not required to purchase, continue to purchase or renew an insurance policy in exchange for the noncash gift, item or service.

(e) No insurance company doing business in this state, attorney, producer or any other person, shall:

(1) Offer or provide insurance as an inducement to purchase another policy; or

(2) Use the word “free”, the phrase “no cost” or any word or phrase of similar import in any advertisement.

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

See Sec. 38a-816 re unfair practices.

Annotation to former section 38-59:

Claim that act which permitted filing of rating plan in which individual insurer's judgment as to expense provisions or hazards of a particular risk may reflect cost of providing coverage and, in turn, the amount of the premium, amounts to rebating, held invalid. 153 C. 465, 477.
Conn. Gen. Stat. § 38a-495a — Connecticut Code / Title 38a / Chapter 700c / Section 38a-495a
Sec. 38a-495a. Medicare supplement policies and certificates. Minimum required policy benefits and standards. Regulations.
Status: in_force

(1) “Applicant” means (A) in the case of an individual Medicare supplement policy, a person who seeks to contract for insurance benefits or (B) in the case of a group Medicare supplement policy, a proposed certificate holder.

(2) “Certificate” means any certificate delivered or issued for delivery in this state under a group Medicare supplement policy.

(3) “Certificate form” means a form on which the certificate is delivered or issued for delivery by an insurer.

(4) “Commissioner” means the Insurance Commissioner.

(5) “Issuer” means any insurance company, fraternal benefit society, hospital service corporation, medical service corporation, health care center or any other entity that delivers or issues for delivery, in this state, any Medicare supplement policies or certificates.

(6) “Medicare” means the Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965, as then constituted or later amended.

(7) “Medicare supplement policy” means (A) a group or individual policy of accident and sickness insurance or (B) a subscriber contract of hospital service corporations, medical service corporations or health care centers, other than a policy issued pursuant to a contract under Section 1876 of the federal Social Security Act, 42 USC 1395 et seq., or (C) an issued policy under a demonstration project specified in 42 USC 1395ss(g)(1), that is advertised, marketed or designed primarily as a supplement to reimbursements under Medicare for the hospital, medical or surgical expenses of persons eligible for Medicare.

(8) “Policy form” means the form on which the policy is delivered or issued for delivery by the issuer.

(b) Except as otherwise specifically excluded, this section shall apply to all Medicare supplement policies and certificates delivered or issued for delivery in this state on or after July 30, 1992.

(c) This section shall not apply to a policy of one or more employers or labor organizations, or of the trustees of a fund established by one or more employers or labor organizations, or combination thereof, for employees or former employees or a combination thereof, or for members or former members, or a combination thereof, of the labor organizations.

(d) Except as otherwise specifically provided in subdivision (4) of subsection (l) of this section, the provisions of this section shall not apply to insurance policies or health care benefit plans provided to Medicare eligible persons which policies are not marketed or held to be Medicare supplement policies or benefit plans.

(e) No Medicare supplement policy or certificate in force in this state shall contain benefits that duplicate benefits provided by Medicare.

(f) Notwithstanding any other provision of law, a Medicare supplement policy or certificate shall not exclude or limit benefits for losses incurred more than six months from the effective date of coverage because it involved a preexisting condition. The policy or certificate shall not define a preexisting condition more restrictively than a condition for which medical advice was given or treatment was recommended by or received from a physician within six months before the effective date of coverage.

(g) The commissioner shall adopt regulations in accordance with chapter 54 to establish specific standards for policy provisions of Medicare supplement policies and certificates. No requirements of this title relating to minimum required policy benefits, other than the minimum standards contained in this section, shall apply to Medicare supplement policies and certificates. The standards may include but need not be limited to the following: (1) Terms of renewability; (2) initial and subsequent conditions of eligibility; (3) nonduplication of coverage; (4) probationary periods; (5) benefit limitations, exceptions and reductions; (6) elimination periods; (7) requirements for replacement; (8) recurrent conditions; and (9) definitions of terms.

(h) The commissioner shall adopt regulations, in accordance with chapter 54, to establish minimum standards for benefits, claim payments, marketing practices, compensation arrangements and reporting practices for Medicare supplement policies and certificates.

(i) The commissioner may adopt such regulations, in accordance with chapter 54, as are necessary to conform Medicare supplement policies and certificates to the requirements of federal law. Such regulations may include but need not be limited to: (1) Requiring refunds or credits if the policies or certificates do not meet loss ratio requirements; (2) establishing a uniform methodology for calculating and reporting loss ratios; (3) assuring public access to policies, premiums and loss ratio information of issuers of Medicare supplement insurance; (4) establishing a process for approving or disapproving policy forms, certificate forms and proposed premium increases; (5) establishing a policy for holding public hearings prior to approval of premium increases; and (6) establishing standards for Medicare select policies and certificates.

(j) The commissioner may adopt regulations, in accordance with chapter 54, that specify prohibited policy provisions not otherwise specifically authorized which in the opinion of the commissioner, are unjust, unfair or unfairly discriminatory to any person insured or proposed to be insured under a Medicare supplement policy or certificate.

(k) Medicare supplement policies shall return to policyholders benefits which are reasonable in relation to the premiums charged. The commissioner shall adopt regulations, in accordance with chapter 54, to establish minimum standards for loss ratios of Medicare supplement policies on the basis of incurred claim experience, or incurred health care expenses where coverage is provided by a health care center on a service rather than a reimbursement basis, and earned premiums in accordance with accepted actuarial principles and practices.

(l) (1) In order to provide for full and fair disclosure in the sale of Medicare supplement policies, no Medicare supplement policy or certificate shall be delivered in this state unless an outline of coverage is delivered to the applicant at the time application is made.

(2) The commissioner shall adopt regulations in accordance with the provisions of chapter 54 to prescribe the format and content of the outline of coverage required by this subsection. For purposes of this subsection, “format” means style, arrangements and overall appearance, including such items as the size, color and prominence of type and arrangement of text and captions. The outline of coverage shall include: (A) A description of the principal benefits and coverage provided in the policy; (B) a statement of the renewal provisions, including any reservation by the issuer of a right to change premiums; and (C) a statement that the outline of coverage is a summary of the policy issued or applied for and that the policy should be consulted to determine the governing contractual provisions.

(3) The commissioner may prescribe by regulation a standard form and the contents of an informational brochure for persons eligible for Medicare, which is intended to improve the buyer's ability to select the most appropriate coverage and improve the buyer's understanding of Medicare. Except for direct response insurance policies, the commissioner may require by regulation that the informational brochure be provided to any prospective insured eligible for Medicare concurrently with the delivery of the outline of coverage. With respect to direct response insurance policies, the commissioner may require by regulation that the prescribed brochure be provided upon request to any prospective insured eligible for Medicare, but in no event later than the time of policy delivery.

(4) The commissioner may adopt regulations, in accordance with chapter 54, for captions or notice requirements, determined to be in the public interest and designed to inform the prospective insured that particular insurance coverages are not Medicare supplement coverages, for all accident and sickness insurance policies sold to persons eligible for Medicare, other than: (A) Medicare supplement policies; or (B) disability income policies.

(5) The commissioner may adopt regulations, in accordance with chapter 54, to govern the full and fair disclosure of the information in connection with the replacement of accident and sickness policies, subscriber contracts or certificates by persons eligible for Medicare.

(m) Medicare supplement policies and certificates shall have a notice prominently printed on the first page of the policy or certificate or attached thereto stating in substance that the applicant shall have the right to return the policy or certificate within thirty days of its delivery and to have the premium refunded if, after examination of the policy or certificate, the applicant is not satisfied for any reason. Any refund made pursuant to this section shall be paid directly to the applicant by the issuer in a timely manner.

(n) Every issuer of Medicare supplement insurance policies or certificates in this state shall provide a copy of any Medicare supplement advertisement intended for use in this state, whether through written, radio or television medium to the commissioner for his review or approval to the extent required by regulations, adopted pursuant to section 38a-819 .

(o) In addition to any other applicable penalties for violations of this title, the commissioner may require issuers violating any provision of this section or any regulations promulgated pursuant to this section to cease marketing any Medicare supplement policies or certificates in this state which is related directly or indirectly to a violation or take such actions as are necessary to comply with the provisions of this section, or both.

See Sec. 38a-495 re Medicare supplement policies and certificates.

See Sec. 38a-522 re group Medicare supplement policies and certificates.
Conn. Gen. Stat. § 38a-477g — Connecticut Code / Title 38a / Chapter 700c / Section 38a-477g
Sec. 38a-477g. Contracts between health carriers and participating providers.
Status: in_force

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(e) The commissioner shall not act to arbitrate, mediate or settle (1) disputes regarding a health carrier's decision not to include a health care provider or facility in such health carrier's network or network plan, or (2) any other dispute between a health carrier, such health carrier's intermediary or one or more participating providers, that arises under or by reason of a participating provider contract or the termination of such contract.
Conn. Gen. Stat. § 38a-364 — Connecticut Code / Title 38a / Chapter 700 / Section 38a-364
Sec. 38a-364. (Formerly Sec. 38-319a). Insurance identification cards. Temporary card to be issued with binder.
Status: in_force

(b) Each insurance company that issues private passenger motor vehicle liability insurance providing the security required by sections 38a-19 and 38a-363 to 38a-388 , inclusive, shall issue annually to each such insured an automobile insurance identification card, in duplicate, for each insured vehicle, one of which shall be presented to the commissioner as provided in section 14-12b and the other carried in the vehicle as provided in section 14-13 . Except as provided in subsection (c) of this section, such card shall be effective for a period of one year and shall include the name of the insured and insurer, the policy number, the effective date of coverage, the year, make or model and vehicle identification number of the insured vehicle, the company code number assigned to the insurer by the National Association of Insurance Commissioners and an appropriate space wherein the insured may set forth the year, make or model and vehicle identification number of any private passenger motor vehicle that becomes covered as a result of a change in the covered vehicle during the effective period of the identification card. When an insured has five or more private passenger motor vehicles registered in this state, the insurer may use the designation “all owned vehicles” on each card in lieu of a specific vehicle description. Each insurance company that delivers, issues for delivery or renews such private passenger motor vehicle liability insurance in this state shall include on such card, the following notice, printed in capital letters and boldface type:

NOTICE:

YOU HAVE THE RIGHT TO CHOOSE THE LICENSED REPAIR SHOP WHERE THE DAMAGE TO YOUR MOTOR VEHICLE WILL BE REPAIRED.

(c) Whenever a binder for such insurance is issued by an agent, the agent shall also issue a temporary identification card, in duplicate, for each covered vehicle effective for a period of sixty days from the date on which the binder becomes effective. Such temporary cards shall include the name of the insured and insurer, the company code number assigned to the insurer by the National Association of Insurance Commissioners, the printed name and signature of the agent or authorized representative, the effective date of the binder, the policy number or, if such number is not available, the agent's code number and the year, make or model and vehicle identification number of the insured vehicle.

(d) The provisions of this section shall apply only to private passenger motor vehicles registered in this state.

See Sec. 14-12f re exempt vehicles.

Annotation to former section 38-319a:

Cited. 186 C. 507.
Conn. Gen. Stat. § 38a-479bb — Connecticut Code / Title 38a / Chapter 700c / Section 38a-479bb
Sec. 38a-479bb. Requirements for managed care organizations that contract with preferred provider networks. Requirements for preferred provider networks.
Status: in_force

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

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

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

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

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

(4) Any other information the commissioner may require.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(m) Nothing in this part or part 1a of this chapter shall be construed to require a preferred provider network to share proprietary information with a managed care organization concerning contracts or financial arrangements with providers who are not included in that managed care organization's network, or other preferred provider networks or managed care organizations.
Conn. Gen. Stat. § 38a-140 — Connecticut Code / Title 38a / Chapter 698 / Section 38a-140
Sec. 38a-140. (Formerly Sec. 38-39l). Remedial and penal provisions.
Status: in_force

(2) No security that is the subject of any agreement or arrangement regarding acquisition, or that is acquired or to be acquired, in contravention of the provisions of sections 38a-129 to 38a-140 , inclusive, or of any regulation or order issued by the commissioner hereunder may be voted at any shareholders' meeting, or may be counted for quorum purposes, and any action of shareholders requiring the affirmative vote of a percentage of shares may be taken as though such securities were not issued and outstanding; but no action taken at any such meeting shall be invalidated by the voting of such securities, unless the action would materially affect control of the insurer or unless the courts of this state have so ordered. If an insurer or the commissioner has reason to believe that any security of the insurer has been or is about to be acquired in contravention of the provisions of sections 38a-129 to 38a-140 , inclusive, or of any regulation or order issued by the commissioner hereunder, the insurer or the commissioner may apply to the superior court or any judge thereof for the judicial district of Hartford, to enjoin any offer, request, invitation, agreement or acquisition made in contravention of sections 38a-129 to 38a-140 , inclusive, or any regulation or order issued by the commissioner thereunder to enjoin the voting of any security so acquired, to void any vote of such security already cast at any meeting of shareholders and for such other equitable relief as the nature of the case and the interest of the insurer's policyholders, creditors and shareholders or the public may require.

(3) In any case where a person has acquired or is proposing to acquire any voting securities in violation of sections 38a-129 to 38a-140 , inclusive, or any regulation or order issued by the commissioner hereunder, the superior court for the judicial district of Hartford, on notice as the court deems appropriate, upon application of the insurer or the commissioner, may seize or sequester any voting securities of the insurer owned directly or indirectly by the person, and issue the order with respect thereto as may be appropriate to effectuate the purposes of sections 38a-129 to 38a-140 , inclusive.

(4) Notwithstanding any other provisions of law, for the purposes of sections 38a-129 to 38a-140 , inclusive, the situs of the ownership of the securities of domestic insurers shall be deemed to be in this state.

(b) Whenever it appears to the commissioner that any person has committed a violation of sections 38a-129 to 38a-140 , inclusive, that so impairs the financial condition of a domestic insurance company as to threaten insolvency or make the further transaction of business by it hazardous to its policyholders, creditors, securityholders or the public, the commissioner may proceed as provided in chapter 704c to take possession of the property of such domestic insurance company and to conduct the business thereof.

(c) (1) Whenever it appears to the commissioner that any insurance company or any director, officer, employee or agent thereof has committed a wilful violation of sections 38a-129 to 38a-140 , inclusive, the commissioner may cause criminal proceedings to be instituted by the state's attorney for the judicial district in which the principal office of the insurance company is located or, if such insurance company has no such office in the state, by the state's attorney for the judicial district of Hartford against such insurance company or the responsible director, officer, employee or agent thereof. Any insurance company that wilfully violates said sections shall be fined not more than fifty thousand dollars. Any individual who wilfully violates said sections shall be fined not more than fifteen thousand dollars or, if such wilful violation involves the deliberate perpetration of a fraud upon the commissioner, shall be imprisoned not more than two years or so fined, or both.

(2) Any officer, director or employee of an insurance holding company system who wilfully and knowingly subscribes to or makes or causes to be made any false statement or false report or false filing with the intent to deceive the commissioner in the performance of the commissioner's duties under sections 38a-129 to 38a-140 , inclusive, upon conviction thereof, shall be guilty of a class D felony, except that such officer, director or employee shall be fined not more than fifty thousand dollars. Any fines imposed shall be paid by the officer, director or employee in his or her individual capacity.

(d) (1) Whenever it appears to the commissioner that any person has committed a violation of sections 38a-129 to 38a-140 , inclusive, that makes the continued operation of an insurance company contrary to the interests of its policyholders or the public, the commissioner may, after giving notice and an opportunity to be heard, suspend, revoke or refuse to renew such insurance company's license or authority to do business in this state for such period as the commissioner finds is required for the protection of its policyholders or the public.

(2) Whenever it appears to the commissioner that any person has committed a violation of sections 38a-129 to 38a-140 , inclusive, that prevents the full understanding of the enterprise risk posed by an insurer's insurance holding company system or an insurer's affiliate to such insurer, the commissioner may disapprove dividends and other distributions and place such insurer under administrative supervision in accordance with sections 38a-962 to 38a-962j , inclusive.

(e) Any insurance company failing, without just cause, to file any registration statement as required in section 38a-135 shall be fined, after notice and hearing, one hundred fifty dollars for each day's delay, to be paid into the Insurance Fund established under section 38a-52a . The maximum penalty under this section shall be fifteen thousand dollars. The commissioner may reduce the penalty if the insurance company demonstrates to the commissioner that the imposition of the penalty would constitute a hardship to the insurance company.

(f) Each director or officer of any insurance holding company system who wilfully and knowingly violates, participates in, or assents to, or who wilfully and knowingly permits any of the officers or agents of the insurance company to engage in transactions or make investments that have not been properly reported or submitted pursuant to section 38a-135 or 38a-136 , or that violate sections 38a-129 to 38a-140 , inclusive, shall pay, in their individual capacity, a civil forfeiture of not more than seven thousand five hundred dollars per violation, after notice and hearing before the commissioner. Any civil forfeiture so recovered shall be paid into the Insurance Fund as established under section 38a-52a . In determining the amount of the civil forfeiture, the commissioner shall take into account the appropriateness of the forfeiture with respect to the gravity of the violation, the history of previous violations, and such other matters as the commissioner deems necessary.

(g) Whenever it appears to the commissioner that any insurance company subject to sections 38a-129 to 38a-140 , inclusive, or any director, officer, employee or agent thereof has engaged in any transaction or entered into a contract that is subject to section 38a-136 and that would not have been approved had such approval been requested, the commissioner may order the insurance company to cease and desist immediately any further activity under such transaction or contract. After notice and hearing, the commissioner may also order the insurance company to void any such contracts and restore the status quo if such action is in the best interests of the policyholders, creditors or the public.

(h) If any person required to file an information statement under subsection (b) of section 38a-130 or any required amendment thereto has (1) failed to do so within the prescribed time, (2) files a false or misleading information statement or amendment thereto, (3) obstructed the conduct of any hearing required by the commissioner, or (4) consummated a change of control of the domestic insurance company in the absence of a determination by the commissioner that such change of control would not be prejudicial to the interest of its policyholders, the commissioner and any interested party, including the domestic insurance company, may apply to the superior court for the judicial district of Hartford or to the superior court for the judicial district in which the domestic insurance company has its principal place of business, or to any judge thereof, for any injunctive or other relief necessary to remedy any such act or failure to act. Such relief may include an injunction prohibiting any consummation of the change of control until such act or failure to act is remedied. In addition, the commissioner may proceed under section 38a-912 for an order permitting the commissioner to take possession and control of the property and affairs of the domestic insurance company in accordance with the provisions of said section 38a-912 .

Annotation to former section 38-39 l :

Cited. 184 C. 352.
Conn. Gen. Stat. § 38a-102a — Connecticut Code / Title 38a / Chapter 698 / Section 38a-102a
Sec. 38a-102a. Nonadmitted investment assets. Divestiture order, notice and hearing.
Status: in_force

(b) Whenever a domestic insurer, as defined in section 38a-1 , holds nonadmitted investment assets exceeding fifty per cent of the amount by which capital and surplus exceeds the minimum requirements for such company or whenever the investments in any category exceed twice the limitations imposed thereon, the Insurance Commissioner may, after reasonable notice to and hearing of such company, direct the orderly divestiture of any or all of such excess. In addition to such an order, the Insurance Commissioner may require the chief investment officer, or in the absence of any such designee, the chief executive officer, of such company to affix to each financial statement required to be filed with the commissioner, a certification that any such order has been complied with or containing the details and explanation of any noncompliance.
Conn. Gen. Stat. § 38a-718 — Connecticut Code / Title 38a / Chapter 701a / Section 38a-718
Sec. 38a-718. (Formerly Sec. 38-76c). Restrictions on negotiation of insurance incidental to extension of credit.
Status: in_force

(b) No person, partnership, association or corporation licensed under the provisions of section 38a-769 , which is owned or controlled, directly or indirectly, by a bank holding company or lending institution, shall negotiate any policy of insurance applicable to any real or personal property which is security for an extension of credit by any lending institution, if approval of the transaction is contingent on the purchase of said insurance.

(c) The terms of this section shall not be construed to apply to any person, partnership, association or corporation owned or controlled by a bank holding company or any lending institution engaged in the activity prohibited hereby on December 31, 1971.
Conn. Gen. Stat. § 38a-514 — Connecticut Code / Title 38a / Chapter 700c / Section 38a-514
Sec. 38a-514. (Formerly Sec. 38-174d). Mandatory coverage for the diagnosis and treatment of mental or nervous conditions. Exceptions. Benefits payable re type of provider or facility. State's claims against proceeds. Direct reimbursement for certain covered services rendered by certain out-of-network providers.
Status: in_force

(1) (A) “Mental or nervous conditions” means mental disorders, as defined in the most recent edition of the American Psychiatric Association's “Diagnostic and Statistical Manual of Mental Disorders”.

(B) “Mental or nervous conditions” does not include (i) intellectual disability, (ii) specific learning disorders, (iii) motor disorders, (iv) communication disorders, (v) caffeine-related disorders, (vi) relational problems, and (vii) other conditions that may be a focus of clinical attention, that are not otherwise defined as mental disorders in the most recent edition of the American Psychiatric Association's “Diagnostic and Statistical Manual of Mental Disorders”.

(2) “Benefits payable” means the usual, customary and reasonable charges for treatment deemed necessary under generally accepted medical standards, except that in the case of a managed care plan, as defined in section 38a-478 , “benefits payable” means the payments agreed upon in the contract between a managed care organization, as defined in section 38a-478 , and a provider, as defined in section 38a-478 .

(3) “Acute treatment services” means twenty-four-hour medically supervised treatment for a substance use disorder, that is provided in a medically managed or medically monitored inpatient facility.

(4) “Clinical stabilization services” means twenty-four-hour clinically managed postdetoxification treatment, including, but not limited to, relapse prevention, family outreach, aftercare planning and addiction education and counseling.

(b) Except as provided in subsection (j) of this section, each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide benefits for the diagnosis and treatment of mental or nervous conditions. Benefits payable include, but need not be limited to:

(1) General inpatient hospitalization, including in state-operated facilities;

(2) Medically necessary acute treatment services and medically necessary clinical stabilization services;

(3) General hospital outpatient services, including at state-operated facilities;

(4) Psychiatric inpatient hospitalization, including in state-operated facilities;

(5) Psychiatric outpatient hospital services, including at state-operated facilities;

(6) Intensive outpatient services, including at state-operated facilities;

(7) Partial hospitalization, including at state-operated facilities;

(8) Intensive, home-based or evidence-based services designed to address specific mental or nervous conditions in a child or adolescent;

(9) Evidence-based family-focused therapy that specializes in the treatment of juvenile substance use disorders;

(10) Short-term family therapy intervention;

(11) Nonhospital inpatient detoxification;

(12) Medically monitored detoxification;

(13) Ambulatory detoxification;

(14) Inpatient services at psychiatric residential treatment facilities;

(15) Rehabilitation services provided in residential treatment facilities, general hospitals, psychiatric hospitals or psychiatric facilities;

(16) Observation beds in acute hospital settings;

(17) Psychological and neuropsychological testing conducted by an appropriately licensed health care provider;

(18) Trauma screening conducted by a licensed behavioral health professional;

(19) Depression screening, including maternal depression screening, conducted by a licensed behavioral health professional; and

(20) Substance use screening conducted by a licensed behavioral health professional.

(c) No such group policy shall establish any terms, conditions or benefits that place a greater financial burden on an insured for access to diagnosis or treatment of mental or nervous conditions than for diagnosis or treatment of medical, surgical or other physical health conditions, or prohibit an insured from obtaining or a health care provider from being reimbursed for multiple screening services as part of a single-day visit to a health care provider or a multicare institution, as defined in section 19a-490 .

(d) In the case of benefits payable for the services of a licensed physician, such benefits shall be payable for the same services when such services are lawfully rendered by a psychologist licensed under the provisions of chapter 383 or by such a licensed psychologist in a licensed hospital or clinic.

(e) In the case of benefits payable for the services of a licensed physician or psychologist, such benefits shall be payable for the same services when such services are rendered by:

(1) A clinical social worker who is licensed under the provisions of chapter 383b and who has passed the clinical examination of the American Association of State Social Work Boards and has completed at least two thousand hours of post-master's social work experience in a nonprofit agency qualifying as a tax-exempt organization under Section 501(c) of the Internal Revenue Code of 1986 or any subsequent corresponding internal revenue code of the United States, as from time to time amended, in a municipal, state or federal agency or in an institution licensed by the Department of Public Health under section 19a-490 ;

(2) A social worker who was certified as an independent social worker under the provisions of chapter 383b prior to October 1, 1990;

(3) A licensed marital and family therapist who has completed at least two thousand hours of post-master's marriage and family therapy work experience in a nonprofit agency qualifying as a tax-exempt organization under Section 501(c) of the Internal Revenue Code of 1986 or any subsequent corresponding internal revenue code of the United States, as from time to time amended, in a municipal, state or federal agency or in an institution licensed by the Department of Public Health under section 19a-490 ;

(4) A marital and family therapist who was certified under the provisions of chapter 383a prior to October 1, 1992;

(5) A licensed alcohol and drug counselor, as defined in section 20-74s , or a certified alcohol and drug counselor, as defined in section 20-74s ;

(6) A licensed professional counselor; or

(7) An advanced practice registered nurse licensed under the provisions of chapter 378.

(f) (1) In the case of benefits payable for the services of a licensed physician, such benefits shall be payable for (A) services rendered in a child guidance clinic or residential treatment facility by a person with a master's degree in social work or by a person with a master's degree in marriage and family therapy under the supervision of a psychiatrist, physician, licensed marital and family therapist or licensed clinical social worker who is eligible for reimbursement under subdivisions (1) to (4), inclusive, of subsection (e) of this section; (B) services rendered in a residential treatment facility by a licensed or certified alcohol and drug counselor who is eligible for reimbursement under subdivision (5) of subsection (e) of this section; or (C) services rendered in a residential treatment facility by a licensed professional counselor who is eligible for reimbursement under subdivision (6) of subsection (e) of this section.

(2) In the case of benefits payable for the services of a licensed psychologist under subsection (e) of this section, such benefits shall be payable for (A) services rendered in a child guidance clinic or residential treatment facility by a person with a master's degree in social work or by a person with a master's degree in marriage and family therapy under the supervision of such licensed psychologist, licensed marital and family therapist or licensed clinical social worker who is eligible for reimbursement under subdivisions (1) to (4), inclusive, of subsection (e) of this section; (B) services rendered in a residential treatment facility by a licensed or certified alcohol and drug counselor who is eligible for reimbursement under subdivision (5) of subsection (e) of this section; or (C) services rendered in a residential treatment facility by a licensed professional counselor who is eligible for reimbursement under subdivision (6) of subsection (e) of this section.

(g) In the case of benefits payable for the service of a licensed physician practicing as a psychiatrist or a licensed psychologist, under subsection (e) of this section, such benefits shall be payable for outpatient services rendered (1) in a nonprofit community mental health center, as defined by the Department of Mental Health and Addiction Services, in a nonprofit licensed adult psychiatric clinic operated by an accredited hospital or in a residential treatment facility; (2) under the supervision of a licensed physician practicing as a psychiatrist, a licensed psychologist, a licensed marital and family therapist, a licensed clinical social worker, a licensed or certified alcohol and drug counselor, or a licensed professional counselor who is eligible for reimbursement under subdivisions (1) to (6), inclusive, of subsection (e) of this section; and (3) within the scope of the license issued to the center or clinic by the Department of Public Health or to the residential treatment facility by the Department of Children and Families.

(h) Except in the case of emergency services, services rendered to an insured at an urgent crisis center, as defined in section 38a-477aa , or services for which an individual has been referred by a physician affiliated with a health care center, nothing in this section shall be construed to require a health care center to provide benefits under this section through facilities that are not affiliated with the health care center.

(i) In the case of any person admitted to a state institution or facility administered by the Department of Mental Health and Addiction Services, Department of Public Health, Department of Children and Families or the Department of Developmental Services, the state shall have a lien upon the proceeds of any coverage available to such person or a legally liable relative of such person under the terms of this section, to the extent of the per capita cost of such person's care. Except in the case of emergency services the provisions of this subsection shall not apply to coverage provided under a managed care plan, as defined in section 38a-478 .

(j) A group health insurance policy may exclude the benefits required by this section 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. Such separate policy, which shall include the benefits required by this section and the benefits required by section 38a-533 , shall not be required to include any other benefits mandated by this title.

(k) In the case of benefits based upon confinement in a residential treatment facility, such benefits shall be 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.

(l) The services rendered for which benefits are to be paid for confinement in a residential treatment facility shall be based on an individual treatment plan. For purposes of this section, the term “individual treatment plan” means 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.

(m) Reimbursement for covered services rendered in this state by an out-of-network health care provider for the diagnosis or treatment of a substance use disorder shall be paid under the insured's group health insurance policy directly to the provider if the provider is otherwise eligible for reimbursement for such services. The insured who received such services shall be deemed to have made an assignment to such provider of such insured's coverage reimbursement benefits and other rights under the policy. In no event shall such provider bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from or have any recourse against the insured for such services, except that such provider may collect any copayments, deductibles or other out-of-pocket expenses that the insured is required to pay under the policy.

See Sec. 38a-488a for similar provisions re individual policies.
Conn. Gen. Stat. § 38a-71 — Connecticut Code / Title 38a / Chapter 698 / Section 38a-71
Sec. 38a-71. Minimum asset requirements. Minimum capital and minimum surplus requirements.
Status: in_force

(1) “Qualified assets” means:

(A) Investments, securities, properties and loans permitted or authorized by law, and the income due thereon;

(B) The net amount of uncollected and deferred premiums for a life insurer which carries the full annual mean tabular reserve liability;

(C) Premiums in the course of collection, other than for life insurance, not more than ninety days past due, with the ninety-day limitation being inapplicable to premiums payable directly or indirectly by the United States government or any of its instrumentalities;

(D) Installment premiums, other than life insurance premiums, in accordance with the regulations adopted by the commissioner in accordance with the provisions of chapter 54, or in the absence of these regulations then in accordance with practices formulated or adopted by the National Association of Insurance Commissioners;

(E) Notes and similar written obligations which are not past due, taken for premiums other than life insurance premiums, on policies permitted to be issued on that basis, to the extent of the unearned premium reserves carried on the policies;

(F) Amounts recoverable or receivable from reinsurers under a reinsurance contract;

(G) Tangible components of health care delivery systems for health care centers governed by sections 38a-175 to 38a-194 , inclusive, with the cost of these assets having a finite useful life being depreciated in full over periods provided by regulations adopted by the commissioner in accordance with the provisions of chapter 54;

(H) Electronic data processing equipment and operating software, the cost of which is depreciated in full over a period not to exceed three years;

(I) Tangible components of the service delivery systems of legal service corporations governed by sections 38a-230 to 38a-245 , inclusive, with the cost of these assets having a finite useful life being depreciated in full over periods provided by regulations adopted by the commissioner in accordance with the provisions of chapter 54;

(J) Cash or currency; and

(K) Other assets authorized by regulations adopted by the commissioner in accordance with the provisions of chapter 54.

(2) “Minimum capital and minimum surplus” means the capital and surplus that must constantly be maintained by a stock insurance company as required by section 38a-72 .

(3) “Surplus” means total statutory surplus less capital stock, adjusted for the par value of any treasury stock, calculated in accordance with the National Association of Insurance Commissioners Accounting Practices and Procedures Manual, version effective January 1, 2001, and subsequent revisions. Except for assessable mutuals, the minimum surplus of a mutual insurer is essentially the same as the minimum required capital requirement which applies to stock-insurers.

(4) “Capital” means the capital stock component of statutory surplus, as defined in the National Association of Insurance Commissioners Accounting Practices and Procedures Manual, version effective January 1, 2001, and subsequent revisions.

(b) Each insurer authorized to do business in this state shall maintain qualified assets in the amount equal to the total of the insurer's (1) liabilities, and (2) minimum capital and minimum surplus required under section 38a-72 .
Conn. Gen. Stat. § 38a-371 — Connecticut Code / Title 38a / Chapter 700 / Section 38a-371
Sec. 38a-371. (Formerly Sec. 38-327). Mandatory security requirements.
Status: in_force

(b) The security required by this section, may be provided by a policy of insurance complying with this section issued by or on behalf of an insurer licensed to transact business in this state or, if the vehicle is registered in another state, by a policy of insurance issued by or on behalf of an insurer licensed to transact business in either this state or the state in which the vehicle is registered.

(c) Subject to approval of the Insurance Commissioner the security required by this section, may be provided by self-insurance by filing with the commissioner in satisfactory form: (1) A continuing undertaking by the owner or other appropriate person to perform all obligations imposed by this section; (2) evidence that appropriate provision exists for the prompt and efficient administration of all claims, benefits, and obligations provided by this section; and (3) evidence that reliable financial arrangements, deposits or commitments exist providing assurance for payment of all obligations imposed by this section substantially equivalent to those afforded by a policy of insurance that would comply with this section. A person who provides security under this subsection is a self-insurer. A municipality may provide the security required under this section by filing with the commissioner a notice that it is a self-insurer.

(d) Except as provided in subsection (b) of section 14-213b , the owner of any private passenger motor vehicle required to be registered in this state who operates it or permits it to be operated in this state is guilty of a class C misdemeanor if he fails to provide the security required by this section.

(e) An owner of a private passenger motor vehicle with respect to which security is required who fails to have such security in effect at the time of an accident shall have all of the rights and obligations of an insurer under sections 38a-363 to 38a-388 , inclusive, and shall remain subject to all the obligations of the Financial Responsibility Law, sections 14-112 to 14-133 , inclusive.

(f) Upon receipt of a signed written request for suspension from the owner of a registered motor vehicle stating that such vehicle will not be operated upon any highway during a period of not less than thirty consecutive days, the insurer of such vehicle shall suspend, to the extent requested by the owner, insurance coverage afforded under the policy providing the security required by sections 38a-363 to 38a-388 , inclusive, for such vehicle until notified by the owner that the coverage should be reinstated. During the period of suspension only, the provisions of subsections (a) to (e), inclusive, of this section shall not apply with respect to such vehicle, except that if such vehicle is operated upon any highway by or with the permission of the owner during the period of suspension, the provisions of said subsections (a) to (e), inclusive, of this section, shall thereupon become applicable. As used in this subsection, “highway” has the same meaning as provided in section 14-1 . This subsection shall not apply to a motor vehicle for which proof of financial responsibility is required under the provisions of sections 14-112 to 14-133 , inclusive.

Annotations to former section 38-327:

Compulsory security requirement of no-fault insurance law applies only to owners of vehicles; criminal prosecution for failure to carry compulsory security cannot be based upon admission made pursuant to Sec. 14-108. 169 C. 267. Cited. 186 C. 507.

Cited. 19 CA 169; 22 CA 27; judgment reversed, see 217 C. 631.

Fault under section does not deprive the uninsured motorist of the benefits of Sec. 38-323; section gives the uninsured motorist the benefit of Sec. 38-323; Subsec. (e) and Sec. 38-323 are construed together. 31 CS 229. Cited. 36 CS 561; 37 CS 117; Id., 672; 38 CS 318.

Annotations to present section:

Cited. 217 C. 631; 219 C. 391; 222 C. 744. Self-insurance provision discussed. 248 C. 195. Legislature's requirement that vehicle owners maintain liability coverage does not require that such owner coverage be primary if other coverage that satisfies the statutory minimum standards is available. 282 C. 535.

Cited. 25 CA 492; judgment reversed, see 222 C. 744; 27 CA 346; 30 CA 742. Self-insured municipal employer not required to create a writing to give notice of its intention to reduce the amount of its uninsured motorist coverage by the amount of workers' compensation benefits paid to plaintiff employee because the self-insured municipality functions as both insurer and insured. 82 CA 752; judgment reversed, see 273 C. 519.
Conn. Gen. Stat. § 38a-530f — Connecticut Code / Title 38a / Chapter 700c / Section 38a-530f
Sec. 38a-530f. Mandatory coverage for certain health benefits and services for women, infants, children and adolescents and certain evidence-based items or services for individuals.
Status: in_force

(A) Domestic and interpersonal violence screening and counseling for any woman;

(B) Tobacco use intervention and cessation counseling for any woman who consumes tobacco;

(C) Well-woman visits for any woman who is younger than sixty-five years of age;

(D) Breast cancer chemoprevention counseling for any woman who is at increased risk for breast cancer due to family history or prior personal history of breast cancer, positive genetic testing or other indications as determined by such woman's physician, physician assistant or advanced practice registered nurse;

(E) Breast cancer risk assessment, genetic testing and counseling;

(F) Chlamydia infection screening for any sexually-active woman;

(G) Cervical and vaginal cancer screening for any sexually-active woman;

(H) Gonorrhea screening for any sexually-active woman;

(I) Human immunodeficiency virus screening for any sexually-active woman;

(J) Human papillomavirus screening for any woman with normal cytology results who is thirty years of age or older;

(K) Sexually transmitted infections counseling for any sexually-active woman;

(L) Anemia screening for any pregnant woman and any woman who is likely to become pregnant;

(M) Folic acid supplements for any pregnant woman and any woman who is likely to become pregnant;

(N) Hepatitis B screening for any pregnant woman;

(O) Rhesus incompatibility screening for any pregnant woman and follow-up rhesus incompatibility testing for any pregnant woman who is at increased risk for rhesus incompatibility;

(P) Syphilis screening for any pregnant woman and any woman who is at increased risk for syphilis;

(Q) Urinary tract and other infection screening for any pregnant woman;

(R) Breastfeeding support and counseling for any pregnant or breastfeeding woman;

(S) Breastfeeding supplies, including, but not limited to, a breast pump for any breastfeeding woman;

(T) Gestational diabetes screening for any woman who is twenty-four to twenty-eight weeks pregnant and any woman who is at increased risk for gestational diabetes;

(U) Osteoporosis screening for any woman who is sixty years of age or older;

(V) Such additional evidence-based items or services not described in subparagraphs (A) to (U), inclusive, of this subdivision that receive a rating of “A” or “B” in any recommendations of the United States Preventive Services Task Force effective after January 1, 2018; and

(W) With respect to infants, children and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the United States Health Resources and Services Administration, as effective on January 1, 2018, and such additional preventive care and screenings provided for in any comprehensive guidelines supported by said administration and effective after January 1, 2018.

(2) No policy described in subdivision (1) of this subsection shall be required to provide coverage for any benefit or service described in subparagraphs (A) to (U), inclusive, of said subdivision unless such benefit or service is an evidence-based item or service that had a rating of “A” or “B” in the recommendations of the United States Preventive Services Task Force as such recommendations were in effect on January 1, 2018.

(b) No policy described in subsection (a) of this section shall impose a coinsurance, copayment, deductible or other out-of-pocket expense for the benefits and services required under said subsection. The provisions of this subsection shall apply to a high deductible health plan, as that term is used in subsection (f) of section 38a-520 , to the maximum extent permitted by federal law, except if such plan is used to establish a medical savings account or an Archer MSA pursuant to Section 220 of the Internal Revenue Code of 1986 or any subsequent corresponding internal revenue code of the United States, as amended from time to time, or a health savings account, as that term is used in Section 223 of said Internal Revenue Code, as amended from time to time, the provisions of this subsection shall apply to such plan to the maximum extent that (1) is permitted by federal law, and (2) does not disqualify such account for the deduction allowed under said Section 220 or 223, as applicable. Nothing in this section shall preclude a policy that provides the coverage required under subsection (a) of this section and uses a provider network from imposing cost-sharing requirements for any benefit or service required under said subsection (a) that is delivered by an out-of-network provider.

See Sec. 38a-503f for similar provisions re individual policies.
Conn. Gen. Stat. § 38a-479cc — Connecticut Code / Title 38a / Chapter 700c / Section 38a-479cc
Sec. 38a-479cc. Duties of a preferred provider network when providing services pursuant to a contract with a managed care organization.
Status: in_force

(b) Whenever a preferred provider network is providing services pursuant to a contract with a managed care organization, the preferred provider network shall pay for the delivery of health care services and operate and maintain arrangements or contracts with providers in a manner consistent with the provisions of law that apply to the managed care organization's contracts with enrollees and providers.
Conn. Gen. Stat. § 38a-503 — Connecticut Code / Title 38a / Chapter 700c / Section 38a-503
Sec. 38a-503. (Formerly Sec. 38-174gg). Mandatory coverage for diagnostic and screening mammography, diagnostic and screening breast ultrasound, diagnostic and screening magnetic resonance imaging, breast biopsies, prophylactic mastectomies and breast reconstructive surgery. Breast density information included in report.
Status: in_force

(1) “Healthcare Common Procedure Coding System” or “HCPCS” means the billing codes used by Medicare and overseen by the federal Centers for Medicare and Medicaid Services that are based on the current procedural technology codes developed by the American Medical Association; and

(2) “Mammogram” means mammographic examination or breast tomosynthesis, including, but not limited to, a procedure with a HCPCS code of 77051, 77052, 77055, 77056, 77057, 77063, 77065, 77066, 77067, G0202, G0204, G0206 or G0279, or any subsequent corresponding code.

(b) (1) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (10), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide benefits for diagnostic and screening mammograms for insureds that are at least equal to the following minimum requirements:

(A) A baseline mammogram, which may be provided by breast tomosynthesis at the option of the insured covered under the policy, for an insured who is:

(i) Thirty-five to thirty-nine years of age, inclusive; or

(ii) Younger than thirty-five years of age if the insured is believed to be at increased risk for breast cancer due to:

(I) A family history of breast cancer;

(II) Positive genetic testing for the harmful variant of breast cancer gene one, breast cancer gene two or any other gene variant that materially increases the insured's risk for breast cancer;

(III) Prior treatment for a childhood cancer if the course of treatment for the childhood cancer included radiation therapy directed at the chest; or

(IV) Other indications as determined by the insured's physician, advanced practice registered nurse, physician assistant, certified nurse midwife or other medical provider; and

(B) Mammograms, which may be provided by breast tomosynthesis at the option of the insured covered under the policy , every year for an insured who is:

(i) Forty years of age or older; or

(ii) Younger than forty years of age if the insured is believed to be at increased risk for breast cancer due to:

(I) A family history, or prior personal history, of breast cancer;

(II) Positive genetic testing for the harmful variant of breast cancer gene one, breast cancer gene two or any other gene that materially increases the insured's risk for breast cancer;

(III) Prior treatment for a childhood cancer if the course of treatment for the childhood cancer included radiation therapy directed at the chest; or

(IV) Other indications as determined by the insured's physician, advanced practice registered nurse, physician assistant, certified nurse midwife or other medical provider.

(2) Such policy shall provide additional benefits for:

(A) Comprehensive diagnostic and screening ultrasounds of an entire breast or breasts if:

(i) A mammogram demonstrates heterogeneous or dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology; or

(ii) An insured is believed to be at increased risk for breast cancer due to:

(I) A family history or prior personal history of breast cancer;

(II) Positive genetic testing for the harmful variant of breast cancer gene one, breast cancer gene two or any other gene that materially increases the insured's risk for breast cancer;

(III) Prior treatment for a childhood cancer if the course of treatment for the childhood cancer included radiation therapy directed at the chest; or

(IV) Other indications as determined by the insured's physician, advanced practice registered nurse, physician assistant, certified nurse midwife or other medical provider;

(B) Diagnostic and screening magnetic resonance imaging of an entire breast or breasts:

(i) In accordance with guidelines established by the American Cancer Society for an insured who is thirty-five years of age or older; or

(ii) If an insured is younger than thirty-five years of age and believed to be at increased risk for breast cancer due to:

(I) A family history, or prior personal history, of breast cancer;

(II) Positive genetic testing for the harmful variant of breast cancer gene one, breast cancer gene two or any other gene that materially increases the insured's risk for breast cancer;

(III) Prior treatment for a childhood cancer if the course of treatment for the childhood cancer included radiation therapy directed at the chest; or

(IV) Other indications as determined by the insured's physician, advanced practice registered nurse, physician assistant, certified nurse midwife or other medical provider;

(C) Breast biopsies;

(D) Prophylactic mastectomies for an insured who is believed to be at increased risk for breast cancer due to positive genetic testing for the harmful variant of breast cancer gene one, breast cancer gene two or any other gene that materially increases the insured's risk for breast cancer; and

(E) Breast reconstructive surgery for an insured who has undergone:

(i) A prophylactic mastectomy; or

(ii) A mastectomy as part of the insured's course of treatment for breast cancer.

(c) Benefits under this section shall be subject to any policy provisions that apply to other services covered by such policy, except that no such policy shall impose a coinsurance, copayment, deductible or other out-of-pocket expense for such benefits. The provisions of this subsection shall apply to a high deductible health plan, as that term is used in subsection (f) of section 38a-493 , to the maximum extent permitted by federal law, except if such plan is used to establish a medical savings account or an Archer MSA pursuant to Section 220 of the Internal Revenue Code of 1986 or any subsequent corresponding internal revenue code of the United States, as amended from time to time, or a health savings account pursuant to Section 223 of said Internal Revenue Code, as amended from time to time, the provisions of this subsection shall apply to such plan to the maximum extent that (1) is permitted by federal law, and (2) does not disqualify such account for the deduction allowed under said Section 220 or 223, as applicable.

(d) Each mammography report provided to an insured shall include information about breast density, based on the Breast Imaging Reporting and Data System established by the American College of Radiology. Where applicable, such report shall include the following notice: “If your mammogram demonstrates that you have dense breast tissue, which could hide small abnormalities, you might benefit from supplementary screening tests, which can include a breast ultrasound screening or a breast MRI examination, or both, depending on your individual risk factors. A report of your mammography results, which contains information about your breast density, has been sent to your physician's, physician assistant's or advanced practice registered nurse's office and you should contact your physician, physician assistant or advanced practice registered nurse if you have any questions or concerns about this report.”.

See Sec. 38a-530 for similar provisions re group policies.
Conn. Gen. Stat. § 38a-769 — Connecticut Code / Title 38a / Chapter 702 / Section 38a-769
Sec. 38a-769. (Formerly Sec. 38-72). Application for license. Regulations. Exceptions.
Status: in_force

(b) Except as provided in subsection (c) of this section, no application for a nonresident license shall be granted unless the applicant holds an equivalent license from any other state. Any application for a resident or nonresident license shall be made for each name or designation under which such business shall be conducted, in such form as the commissioner prescribes, stating the line or lines of insurance for which the applicant desires such license and any other business which the applicant desires also to transact. All initial applications shall be accompanied by a nonrefundable filing fee specified in section 38a-11 . The commissioner shall cause to be made such inquiry and examination as to the qualifications of each such applicant as the commissioner deems necessary.

(c) Any person, partnership, association or corporation residing in a state that does not offer the type of license sought by such person, partnership, association or corporation in this state may make a written application to the commissioner for a nonresident license and designate this state as such person's, association's or corporation's home state.

(d) Each application for a license shall be signed by: The applicant, if the application is for an individual; a licensed officer, if the application is for a corporation; a licensed partner, if the application is for a partnership; and a licensed principal, if the application is for any other applicant.

(e) Each applicant for a license shall furnish satisfactory evidence to the commissioner that the applicant is a person of good moral character and that the applicant is financially responsible. In order to determine the trustworthiness and competency of an applicant the commissioner shall subject the applicant to personal written examination as to the applicant's competency to act as a licensee for each line of insurance for which the applicant desires to be licensed. The commissioner may, at the commissioner's discretion, designate an independent testing service to prepare and administer such examination, provided any examination fees charged by such service shall be paid by the applicant. The commissioner shall collect the appropriate examination fee as specified in section 38a-11 , which shall entitle the applicant to take the examination for the license desired, except that when a testing service is used, the testing service shall pay such fee to the commissioner for each examination taken by an applicant. In either case, each such examination shall be as the commissioner prescribes and shall be of sufficient scope to test the applicant's knowledge of insurance, the duties and responsibilities of a licensee and the laws of this state applicable to insurance. The commissioner may require a waiting period not exceeding six months, before reexamining any applicant who has failed to pass any such examination.

(f) Upon finding that an applicant meets the licensing requirements of this title and is in all respects properly qualified and trustworthy and that the granting of such license is not against the public interest, the commissioner may issue to such applicant the license applied for, in such form as the commissioner may adopt, to act within this state to the extent therein specified.

(g) The commissioner may adopt regulations, in accordance with chapter 54, concerning the approval of schools offering courses in insurance, the content of such courses and the advertising to the public of the services of these schools.

(h) To further the enforcement of this section and to determine the eligibility of any licensee, the commissioner may, as often as the commissioner deems necessary, examine the books and records of any such licensee.

(i) A license may, in the discretion of the commissioner, be renewed or continued upon payment of the appropriate fee as specified in section 38a-11 , without the resubmittal of the detailed information required in the original application.

(j) The provisions of subsections (b) to (i), inclusive, of this section shall be applicable to any licensee or applicant for a license, including, but not limited to, such licensee engaged in, or such applicant who seeks to become licensed to engage in, the occupation of insurance producer.

See Sec. 38a-413 for title agent and title insurer exemption.

See Sec. 38a-772 re misrepresentation in application for license.

See Sec. 38a-773 re impersonation in taking examination.

Annotation to former section 38-72:

Cited. 162 C. 506.

Annotation to present section:

Cited. 45 CA 368. Provisions of section in their entirety are not applicable to insurance producers; Insurance Department's continuous interpretation of applying Subsecs. (c) and (d) to insurance producers since enactment of Sec. 38a-702a et seq. is not reasonable, however, commissioner retains discretion beyond Sec. 38a-702a et seq. to deny insurance producer licenses pursuant to Secs. 46a-80 and 46a-81. 148 CA 234.
Conn. Gen. Stat. § 38a-311 — Connecticut Code / Title 38a / Chapter 700 / Section 38a-311
Sec. 38a-311. (Formerly Sec. 38-102). Forms of supplemental contracts or extended coverage endorsements.
Status: in_force

Annotation to former section 38-102:

Homeowners' policy, which excluded liability for articles covered by more specific insurance, upheld. 2 Conn. Cir. Ct. 112.
Conn. Gen. Stat. § 38a-528a — Connecticut Code / Title 38a / Chapter 700c / Section 38a-528a
Sec. 38a-528a. Group short-term care policies. Approval of rates and forms. Disclosures. Regulations.
Status: in_force

(b) (1) No short-term care policy or certificate shall be delivered or issued for delivery to any resident in this state, nor shall any application, rider or endorsement be used in connection with such policy or certificate, until a copy of the form thereof and of the classification of risks and the premium rates have been filed with the Insurance Commissioner. The commissioner shall adopt regulations, in accordance with the provisions of chapter 54, to establish a procedure for reviewing such policies and certificates. The commissioner shall disapprove the use of such form at any time if the form does not conform to the requirements of law, or if the form contains a provision or provisions that are unfair or deceptive or that encourage misrepresentation of the policy or certificate. The commissioner shall notify, in writing, the insurer that has filed any such form of the commissioner's disapproval, specifying the reasons for disapproval, and ordering that no such insurer shall deliver or issue for delivery to any person in this state a policy or certificate on or containing such form. The provisions of section 38a-19 shall apply to such orders.

(2) No rate filed under the provisions of subdivision (1) of this subsection shall be effective until it has been approved by the commissioner in accordance with regulations adopted pursuant to this subsection. The commissioner shall adopt regulations, in accordance with the provisions of chapter 54, to prescribe standards to ensure that such rates shall not be excessive, inadequate or unfairly discriminatory. The commissioner may disapprove such rate if it fails to comply with such standards.

(c) (1) No insurance company, fraternal benefit society, hospital service corporation, medical service corporation or health care center may deliver or issue for delivery any short-term care policy or certificate without providing, at the time of application or solicitation for purchase or sale of such coverage, full and fair written disclosure of the benefits and limitations of the policy or certificate.

(2) Each applicant for purchase of a short-term care policy or certificate shall sign an acknowledgment at the time of application for such policy or certificate that the company, society, corporation or center has provided the written disclosure required under this subsection to the applicant. If the method of application does not allow for such signature at the time of application, the applicant shall sign such acknowledgment not later than at the time of delivery of such policy or certificate.

(3) Except for a short-term care policy or certificate for which no applicable premium rate revision or rate schedule increases can be made, such disclosure shall include:

(A) A statement in not less than twelve-point boldface type that the policy or certificate does not provide long-term care insurance coverage and is not a long-term care insurance policy or certificate or a Connecticut Partnership for Long-Term Care insurance policy or certificate;

(B) A statement that the policy or certificate may be subject to rate increases in the future;

(C) An explanation of potential future premium rate revisions and the policyholder's or certificate holder's option in the event of a premium rate revision; and

(D) The premium rate or rate schedule applicable to the applicant for purchase of the short-term care policy or certificate that will be in effect until such company, society, corporation or center files a request with the commissioner for a revision to such premium rate or rate schedule.

(d) (1) No insurance company, fraternal benefit society, hospital service corporation, medical service corporation or health care center delivering, issuing for delivery, renewing, continuing or amending any short-term care policy or certificate in this state shall refuse to accept, or refuse to make reimbursement pursuant to, a claim for benefits submitted by or prepared with the assistance of a managed residential community, as defined in section 19a-693 , in accordance with subdivision (7) of subsection (a) of section 19a-694 , solely because such claim for benefits was submitted by or prepared with the assistance of a managed residential community.

(2) Each insurance company, fraternal benefit society, hospital service corporation, medical service corporation or health care center delivering, issuing for delivery, renewing, continuing or amending any short-term care policy or certificate in this state shall, upon receipt of a written authorization executed by the insured, (A) disclose information to a managed residential community for the purpose of determining such insured's eligibility for an insurance benefit or payment, and (B) provide a copy of the initial acceptance or declination of a claim for benefits to the managed residential community at the same time such acceptance or declination is made to the insured.

(e) The commissioner shall adopt regulations, in accordance with the provisions of chapter 54, to implement the provisions of this section. Such regulations shall include, but need not be limited to, (1) the permissible loss ratio for a short-term care policy or certificate, if any, (2) the permissible exclusionary periods for coverage under a short-term care policy or certificate, if any, (3) the circumstances under which a short-term care policy or certificate will be renewable, and (4) the benefits payable under a short-term care policy or certificate in relation to other insurance coverage that provides benefits to the insured.

See Sec. 38a-501a for similar provisions re individual policies.
Conn. Gen. Stat. § 38a-524 — Connecticut Code / Title 38a / Chapter 700c / Section 38a-524
Sec. 38a-524. Coverage for occupational therapy.
Status: in_force

(1) “Occupational therapy” means services provided by a licensed occupational therapist in accordance with a plan of care established and approved in writing by a physician licensed in accordance with the provisions of chapter 370 or an advanced practice registered nurse licensed in accordance with the provisions of chapter 378, who has certified that the prescribed care and treatment are not available from sources other than a licensed occupational therapist and which are provided in private practice or in a licensed health care facility. Such plan shall be reviewed and certified at least every two months by such physician or advanced practice registered nurse.

(2) “Health care facility” means an institution which provides occupational therapy, including, but not limited to, an outpatient clinic, a rehabilitative agency and a skilled or intermediate nursing facility.

(3) “Rehabilitative agency” means an agency which provides an integrated multitreatment program designed to upgrade the function of persons with physical disabilities by bringing together, as a team, specialized personnel from various allied health fields.

(4) “Partial hospitalization” means a formal program of care provided in a hospital or facility for periods of less than twenty-four hours a day.

(b) Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state that provides coverage for expenses incurred for physical therapy shall 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.

See Sec. 38a-496 for similar provisions re individual policies.
Conn. Gen. Stat. § 38a-589 — Connecticut Code / Title 38a / Chapter 700c / Section 38a-589
Sec. 38a-589. (Formerly Sec. 38-174uu). Confidentiality.
Status: in_force

(b) Data or information pertaining to the diagnosis, treatment or health of any enrollee obtained by the dental plan organization from the enrollee or any dentist shall be confidential and shall not be disclosed to any person except to the extent that it may be necessary to carry out the purposes of sections 38a-577 to 38a-590 , inclusive, or upon the express consent of the enrollee, or pursuant to statute or court order for the production of evidence or the discovery thereof, or in the event of claim or litigation between the enrollee and the dental plan organization wherein the data or information is pertinent. A dental plan organization shall be entitled to claim any statutory privileges against such disclosure which the dentist who furnished the information to the dental organization is entitled to claim.
Conn. Gen. Stat. § 38a-470 — Connecticut Code / Title 38a / Chapter 700c / Section 38a-470
Sec. 38a-470. (Formerly Sec. 38-174n). Lien on workers' compensation awards for insurers. Notice of lien.
Status: in_force

(b) Any insurer, hospital service corporation, medical service corporation, health care center or employee welfare benefit plan that furnished benefits or services under a health insurance policy or a self-insured employee welfare benefit plan to any person suffering an injury or illness covered by the Workers' Compensation Act has a lien on the proceeds of any award or approval of any compromise made by an administrative law judge less attorneys' fees approved by the district administrative law judge and reasonable costs related to the proceeding, to the extent of benefits paid or services provided for the effects of the injury or illness arising out of and in the course of employment as a result of a controverted claim, provided such plan, policy or contract provides for reduction, exclusion, or coordination of benefits of the policy or plan on account of workers' compensation benefits.

(c) The lien shall arise at the time such benefits are paid or such services are rendered. The person or entity furnishing such benefits or services shall serve written notice upon the employee, the insurance company providing workers' compensation benefits or the employer, if self-insured, and the administrative law judge for the district in which the claim for workers' compensation has been filed, setting forth the nature and extent of the lien allowable under subsection (b) of this section. The lien shall be effective against any workers' compensation award made after the notice is received.

(d) The written notice shall be served upon the employee at his last-known address, the insurance company at its principal place of business in this state or the employer, if self-insured, at its principal place of business, and the administrative law judge, at the district office. Service shall be made to all parties by certified or registered mail. The notice shall be in duplicate and shall contain, in addition to the information set forth in subsection (c) of this section, the name of the injured or ill employee, the name of the company providing workers' compensation benefits, the amount expended and an estimate of the amount to be expended for benefits or services provided to such injured or ill employee.

(e) The insurance company providing workers' compensation coverage or the employer, if self-insured, shall reimburse the insurance company, hospital service corporation, medical service corporation, health care center or employee welfare benefit plan providing benefits or service directly, to the extent of any such lien. The receipt of such reimbursement by such insurer, hospital service corporation, medical service corporation, health care center or employee welfare benefit plan shall fully discharge such lien.

(f) The validity or amount of the lien may be contested by the workers' compensation carrier, the employer, if self-insured or the employee by bringing an action in the superior court for the judicial district of Hartford or in the judicial district in which the plaintiff resides. Such cases shall have the same privilege with respect to their assignment for trial as appeals from the workers' compensation review division but shall first be claimed for the short calendar unless the court shall order the matter placed on the trial list. An appeal may be taken from the decision of the Superior Court to the Appellate Court in the same manner as is provided in section 51-197b . In any appeal in which one of the parties is not represented by counsel and in which the party taking the appeal does not claim the case for the short calendar or trial within a reasonable time after the return day, the court may of its own motion dismiss the appeal, or the party ready to proceed may move for nonsuit or default as appropriate. During the pendency of the appeal any workers' compensation benefits due shall be paid into the court in accordance with the rules relating to interpleader actions.

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

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

Annotations to former section 38-174n:

Cited. 216 C. 815.

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

Annotations to present section:

Cited. 217 C. 631; 219 C. 439.
Conn. Gen. Stat. § 38a-91aa — Connecticut Code / Title 38a / Chapter 698 / Section 38a-91aa
Sec. 38a-91aa. Captive insurance companies. Definitions.
Status: in_force

(1) “Affiliated company” means any company in the same corporate system as a parent, an industrial insured or a member organization by virtue of common ownership, control, operation or management.

(2) “Agency captive insurance company” means a captive insurance company that:

(A) Is owned or directly or indirectly controlled by one or more insurance agents or insurance producers licensed in accordance with sections 38a-702a to 38a-702r , inclusive;

(B) Only insures against risks covered by insurance policies sold, solicited or negotiated through the insurance agents or insurance producers that own or control such captive insurance company; and

(C) Does not insure against risks covered by any health insurance policy or plan.

(3) “Alien captive insurance company” means any insurance company formed to write insurance business for its parent and affiliated companies and licensed pursuant to the laws of an alien jurisdiction that imposes statutory or regulatory standards on companies transacting the business of insurance in such jurisdiction that the commissioner deems to be acceptable.

(4) “Association” means any legal association of individuals, corporations, limited liability companies, partnerships, associations or other entities, where the association itself or some or all of the member organizations:

(A) Directly or indirectly own, control or hold with power to vote all of the outstanding voting securities or other voting interests of an association captive insurance company incorporated as a stock insurer;

(B) Have complete voting control over an association captive insurance company incorporated as a mutual corporation or formed as a limited liability company; or

(C) Constitute all of the subscribers of an association captive insurance company formed as a reciprocal insurer.

(5) “Association captive insurance company” means any company that insures risks of the member organizations of an association, and includes a company that also insures risks of such member organizations' affiliated companies or of the association.

(6) “Branch business” means any insurance business transacted in this state by a branch captive insurance company.

(7) “Branch captive insurance company” means any alien captive insurance company or foreign captive insurance company licensed by the commissioner to transact the business of insurance in this state through a business unit with a principal place of business in this state.

(8) “Branch operations” means any business operations in this state of a branch captive insurance company.

(9) “Captive insurance company” means any (A) pure captive insurance company, agency captive insurance company, association captive insurance company, industrial insured captive insurance company, risk retention group, sponsored captive insurance company or special purpose financial captive insurance company that is domiciled in this state and formed or licensed under the provisions of this section and sections 38a-91bb to 38a-91tt , inclusive, or (B) branch captive insurance company.

(10) “Ceding insurer” means an insurance company, approved by the commissioner and licensed or otherwise authorized to transact the business of insurance or reinsurance in its state or country of domicile, that cedes risk to a special purpose financial captive insurance company pursuant to a reinsurance contract.

(11) “Commissioner” means the Insurance Commissioner.

(12) “Controlled unaffiliated business” means any person:

(A) Who, (i) in the case of a pure captive insurance company, is not in the corporate system of a parent and the parent's affiliated companies, (ii) in the case of an industrial insured captive insurance company, is not in the corporate system of an industrial insured and the industrial insured's affiliated companies, or (iii) in the case of a sponsored captive insurance company, is not in the corporate system of a participant and the participant's affiliated companies;

(B) Who, (i) in the case of a pure captive insurance company, has an existing contractual relationship with a parent or one of the parent's affiliated companies, (ii) in the case of an industrial insured captive insurance company, has an existing contractual relationship with an industrial insured or one of the industrial insured's affiliated companies, or (iii) in the case of a sponsored captive insurance company, has an existing contractual relationship with a participant or one of the participant's affiliated companies; and

(C) Whose risks are managed by a pure captive insurance company, an industrial insured captive insurance company or a sponsored captive insurance company, as applicable, in accordance with section 38a-91qq .

(13) “Excess workers' compensation insurance” means, in the case of an employer that has insured or self-insured its workers' compensation risks in accordance with applicable state or federal law, insurance in excess of a specified per-incident or aggregate limit established by the commissioner.

(14) “Foreign captive insurance company” means any insurance company formed to write insurance business for its parent and affiliated companies and licensed pursuant to the laws of a foreign jurisdiction that imposes statutory or regulatory standards on companies transacting the business of insurance in such jurisdiction that the commissioner deems to be acceptable.

(15) “Incorporated protected cell” means a protected cell that is established as a corporation or a limited liability company, separate from the sponsored captive insurance company with which it has entered into a participant contract.

(16) “Industrial insured” means an insured:

(A) Who procures the insurance of any risk or risks by use of the services of a full-time employee acting as an insurance manager or buyer;

(B) Whose aggregate annual premiums for insurance on all risks total at least twenty-five thousand dollars; and

(C) Who has at least twenty-five full-time employees.

(17) “Industrial insured captive insurance company” means any company that insures risks of the industrial insureds that comprise an industrial insured group, and includes a company that also insures risks of such industrial insureds' affiliated companies.

(18) “Industrial insured group” means any group of industrial insureds that collectively:

(A) Directly or indirectly own, control or hold with power to vote all of the outstanding voting securities or other voting interests of an industrial insured captive insurance company incorporated as a stock insurer;

(B) Have complete voting control over an industrial insured captive insurance company incorporated as a mutual corporation or formed as a limited liability company; or

(C) Constitute all of the subscribers of an industrial insured captive insurance company formed as a reciprocal insurer.

(19) “Insurance securitization” or “securitization” means a transaction or a group of related transactions, which may include capital market offerings, that are effected through related risk transfer instruments and facilitating administrative agreements, in which all or part of the result of such transaction is used to fund a special purpose financial captive insurance company's obligations under a reinsurance contract with a ceding insurer and by which:

(A) A special purpose financial captive insurance company directly or indirectly obtains proceeds through the issuance of securities by such company or any other person; or

(B) A person provides, for the benefit of a special purpose financial captive insurance company, one or more letters of credit or other assets that the commissioner has authorized such company to treat as admitted assets for purposes of its annual report. “Insurance securitization” or “securitization” does not include the issuance of a letter of credit for the benefit of the commissioner to satisfy all or part of a special purpose financial captive insurance company's capital and surplus requirements under section 38a-91dd .

(20) “Member organization” means any individual, corporation, limited liability company, partnership, association or other entity that belongs to an association.

(21) “Mutual corporation” means a corporation organized without stockholders and includes a nonprofit corporation with members.

(22) “Parent” means any individual, corporation, limited liability company, partnership or other entity that directly or indirectly owns, controls or holds with power to vote more than fifty per cent of the outstanding voting:

(A) Securities of a pure captive insurance company organized as a stock insurer; or

(B) Membership interests of a pure captive insurance company organized as a nonprofit corporation or as a limited liability company.

(23) “Participant” means any association, corporation, limited liability company, partnership, trust or other entity, and any affiliated company or controlled unaffiliated business thereof, that is insured by a sponsored captive insurance company pursuant to a participant contract.

(24) “Participant contract” means a contract entered into by a sponsored captive insurance company and a participant by which the sponsored captive insurance company insures the risks of the participant and limits the losses of each such participant to its pro rata share of the assets of one or more protected cells identified in such participant contract.

(25) “Protected cell” means a separate account established by a sponsored captive insurance company, in which assets are maintained for one or more participants in accordance with the terms of one or more participant contracts to fund the liability of the sponsored captive insurance company assumed on behalf of such participants as set forth in such participant contracts.

(26) “Pure captive insurance company” means any company that insures risks of its parent and affiliated companies or controlled unaffiliated business.

(27) “Reinsurance contract” means a contract entered into by a special purpose financial captive insurance company and a ceding insurer by which the special purpose financial captive insurance company agrees to provide reinsurance to the ceding insurer for risks associated with the ceding insurer's insurance or reinsurance business.

(28) “Risk retention group” means a captive insurance company organized under the laws of this state pursuant to the federal Liability Risk Retention Act of 1986, 15 USC 3901 et seq., as amended from time to time, as a stock insurer or mutual corporation, a reciprocal or other limited liability entity.

(29) “Security” has the same meaning as provided in section 36b-3 and includes any form of debt obligation, equity, surplus certificate, surplus note, funding agreement, derivative or other financial instrument that the commissioner designates as a security for purposes of this section and sections 38a-91bb to 38a-91tt , inclusive.

(30) “Special purpose financial captive insurance company” means a company that is licensed by the commissioner in accordance with section 38a-91bb .

(31) “Special purpose financial captive insurance company security” means a security issued by (A) a special purpose financial captive insurance company, or (B) a third party, the proceeds of which are obtained directly or indirectly by a special purpose financial captive insurance company.

(32) “Sponsor” means any association, corporation, limited liability company, partnership, trust or other entity that is approved by the commissioner to organize and operate a sponsored captive insurance company and to provide all or part of the required unimpaired paid-in capital and surplus.

(33) “Sponsored captive insurance company” means a captive insurance company:

(A) In which the minimum required unimpaired paid-in capital and surplus are provided by one or more sponsors;

(B) That insures risks of its participants only through separate participant contracts; and

(C) That funds its liability to each participant through one or more protected cells and segregates the assets of each protected cell from the assets of other protected cells and from the assets of the sponsored captive insurance company's general account.

(34) “Surplus note” means an unsecured subordinated debt obligation possessing characteristics consistent with the National Association of Insurance Commissioners Statement of Statutory Accounting Principles No. 41, as amended from time to time, and as modified or supplemented by the commissioner.

See Sec. 38a-591j(b) re use of utilization review license fees to implement provisions of Secs. 38a-91aa to 38a-91tt, inclusive.
Conn. Gen. Stat. § 38a-518s — Connecticut Code / Title 38a / Chapter 700c / Section 38a-518s
Sec. 38a-518s. Mandatory coverage for certain preventive care and screenings for individuals who are twenty-one years of age or younger.
Status: in_force

(b) No such policy shall impose a coinsurance, copayment, deductible or other out-of-pocket expense for the benefits and services required under subsection (a) of this section. The provisions of this subsection shall apply to a high deductible health plan, as that term is used in subsection (f) of section 38a-520 , to the maximum extent permitted by federal law, except if such plan is used to establish a medical savings account or an Archer MSA pursuant to Section 220 of the Internal Revenue Code of 1986 or any subsequent corresponding internal revenue code of the United States, as amended from time to time, or a health savings account pursuant to Section 223 of said Internal Revenue Code, as amended from time to time, the provisions of this subsection shall apply to such plan to the maximum extent that (1) is permitted by federal law, and (2) does not disqualify such account for the deduction allowed under said Section 220 or 223, as applicable. Nothing in this section shall preclude a policy that provides the coverage required under subsection (a) of this section and uses a provider network from imposing cost-sharing requirements for any benefit or service required under said subsection (a) that is delivered by an out-of-network provider.

See Sec. 38a-492s for similar provisions re individual policies.
Conn. Gen. Stat. § 38a-923 — Connecticut Code / Title 38a / Chapter 704c / Section 38a-923
Sec. 38a-923. (Formerly Sec. 38-441). Powers of liquidator.
Status: in_force

(b) The enumeration, in this section, of the powers and authority of the liquidator shall not be construed as a limitation upon him, nor shall it exclude in any manner his right to do other acts not specifically enumerated, or otherwise provided for, as may be necessary or appropriate for the accomplishment of or in aid of the purpose of liquidation.

(c) The liquidator shall not be obligated to defend any action against the insurer or insured and may enforce injunctions, stays and the claims procedure set forth in sections 38a-903 to 38a-961 , inclusive. The liquidator may elect to defend any actions against the insurer or insureds if it is in the best interest of the estate. Any insureds not defended by a guaranty association shall provide their own defense, and include the cost of the defense as part of their claims, if the defense was an obligation of the insurer. The rights of the liquidator to contest coverage on a particular claim shall be deemed preserved without the necessity for an express reservation of rights.
Conn. Gen. Stat. § 38a-702e — Connecticut Code / Title 38a / Chapter 701a / Section 38a-702e
Sec. 38a-702e. Application for license. Examination. Waiver of examination requirement. Exception for limited lines producers.
Status: in_force

(b) A business entity acting as an insurance producer shall obtain an insurance producer license. Application shall be made using the uniform business entity application. The commissioner shall not approve the application unless the commissioner finds that (1) the business entity has paid the fees set forth in section 38a-11 ; and (2) the business entity has designated a licensed producer responsible for the business entity's compliance with the insurance laws, rules and regulations of this state.

(c) The commissioner may require the applicant to submit any documents reasonably necessary to verify the information contained in an application.

(d) Each insurer that sells, solicits or negotiates any form of limited line credit insurance shall provide to each individual whose duties will include selling, soliciting or negotiating limited line credit insurance a program of instruction that may be approved by the commissioner.

(e) Each applicant for an insurance producer license shall, before being admitted to an examination under subsection (a) of this section, prove to the satisfaction of the commissioner that such applicant meets one of the following prerequisites: (1) Successful completion of a course approved by the commissioner requiring not less than twenty hours for each line of insurance for which the applicant is applying to be licensed; or (2) equivalent experience or training as determined by the commissioner.

(f) The commissioner may waive the requirement for examination for any applicant who, at any time within the year preceding the date of application for an insurance producer license, was licensed in this state under a license of the same type as the license applied for.

(g) Notwithstanding any provision of chapter 702 or sections 38a-702a to 38a-702r , inclusive, no examination or prelicensing education shall be required of an applicant for a limited lines producer license.

See Sec. 38a-702s re additional grounds for denial of producer licenses.