2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-477d. - *(See end of section for amended version and effective date.) Information to be made available to consumers.

(a) Each insurer, health care center, hospital service corporation, medical service corporation, fraternal benefit society or other entity that delivers, issues for delivery, renews, amends or continues a health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 in this state, shall:
(1) Make available to consumers, in an easily readable, accessible and understandable format, the following information for each such policy: (A) Any coverage exclusions; (B) any restrictions on the use or quantity of a covered benefit, including on prescription drugs or drugs administered in a physician's office or a clinic; (C) a specific description of how prescription drugs are included or excluded from any applicable deductible, including a description of other out-of-pocket expenses that apply to such drugs; (D) the specific dollar amount of any copayment and the percentage of any coinsurance imposed on each covered benefit, including each covered prescription drug; and (E) information regarding any process available to consumers, and all documents necessary, to seek coverage of a noncovered outpatient prescription drug;
(2) Make available to consumers a way to determine accurately (A) whether a specific prescription drug is available under such policy's drug formulary; (B) the coinsurance, copayment, deductible or other out-of-pocket expense applicable to such drug; (C) whether such drug is covered when dispensed by a physician or a clinic; (D) whether such drug requires prior authorization or the use of step therapy; (E) whether specific types of health care specialists are in-network; and (F) whether a specific health care provider or hospital is in-network.
(b) (1) Each insurer, health care center, hospital service corporation, medical service corporation, fraternal benefit society or other entity shall make the information required under subsection (a) of this section available to consumers at the time of enrollment and shall post such information on its Internet web site.
(2) The Connecticut Health Insurance Exchange, established pursuant to section 38a-1081, shall post links on its Internet web site to such information for each qualified health plan that is offered or sold through the exchange.
(c) The Insurance Commissioner shall post links on the Insurance Department's Internet web site to any on-line tools or calculators to help consumers compare and evaluate health insurance policies and plans.
(P.A. 15-146, S. 7; P.A. 17-15, S. 43, 44; P.A. 18-41, S. 11.)
*Note: On and after January 1, 2023, this section, as amended by section 1 of public act 21-22, is to read as follows:
“Sec. 38a-477d. Information to be made available to consumers. Explanations of benefits. Disclosures by health carriers. Specifications by consumers. Restrictions. (a) Each insurer, health care center, hospital service corporation, medical service corporation, fraternal benefit society or other entity that delivers, issues for delivery, renews, amends or continues a health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 in this state, shall:
(1) Make available to consumers, in an easily readable, accessible and understandable format:
(A) The following information for each such policy:
(i) Any coverage exclusions;
(ii) Any restrictions on the use or quantity of a covered benefit, including on prescription drugs or drugs administered in a physician's office or a clinic;
(iii) A specific description of how prescription drugs are included or excluded from any applicable deductible, including a description of other out-of-pocket expenses that apply to such drugs;
(iv) The specific dollar amount of any copayment and the percentage of any coinsurance imposed on each covered benefit, including each covered prescription drug; and
(v) Information regarding any process available to consumers, and all documents necessary, to seek coverage of a noncovered outpatient prescription drug; and
(B) With respect to explanations of benefits issued pursuant to subsections (d) to (i), inclusive, of this section, a statement disclosing that each consumer who is a covered individual and legally capable of consenting to the provision of covered benefits under such policy may specify that such insurer, center, corporation, society or entity, and each third-party administrator, as defined in section 38a-720, providing services to such insurer, center, corporation, society or entity, shall:
(i) Not issue explanations of benefits concerning covered benefits provided to such consumer; or
(ii) (I) Issue explanations of benefits concerning covered benefits provided to such consumer solely to such consumer; and
(II) Use a method specified by such consumer to issue such explanations of benefits solely to such consumer, and provide sufficient space in the statement for such consumer to specify a mailing address or an electronic mail address for such insurer, center, corporation, society, entity or third-party administrator to use to contact such consumer concerning covered benefits provided to such consumer.
(2) Make available to consumers a way to determine accurately:
(A) Whether a specific prescription drug is available under such policy's drug formulary;
(B) The coinsurance, copayment, deductible or other out-of-pocket expense applicable to such drug;
(C) Whether such drug is covered when dispensed by a physician or a clinic;
(D) Whether such drug requires prior authorization or the use of step therapy;
(E) Whether specific types of health care specialists are in-network; and
(F) Whether a specific health care provider or hospital is in-network.
(b) (1) Each insurer, health care center, hospital service corporation, medical service corporation, fraternal benefit society or other entity shall make the information and statement required under subsection (a) of this section available to consumers at the time of enrollment and shall post such information and statement on its Internet web site.
(2) The Connecticut Health Insurance Exchange, established pursuant to section 38a-1081, shall post links on its Internet web site to such information and statement for each qualified health plan that is offered or sold through the exchange.
(c) The Insurance Commissioner shall post links on the Insurance Department's Internet web site to any on-line tools or calculators to help consumers compare and evaluate health insurance policies and plans.
(d) Except as provided in subsection (g) of this section, each insurer, health care center, hospital service corporation, medical service corporation, fraternal benefit society or other entity that delivers, issues for delivery, renews, amends or continues a health insurance policy described in subsection (a) of this section, and each third-party administrator, as defined in section 38a-720, providing services to such an insurer, center, corporation, society or entity, shall:
(1) Issue explanations of benefits to consumers who are covered individuals under the policy; and
(2) Permit each consumer who is a covered individual under the policy and legally capable of consenting to the provision of covered benefits to specify, in writing, that such insurer, center, corporation, society, entity or third-party administrator issue explanations of benefits concerning covered benefits provided to such consumer solely to such consumer, and specify, in writing, which of the following methods such insurer, center, corporation, society, entity or third-party administrator shall use to issue such explanations of benefits solely to such consumer:
(A) Mailing such explanations of benefits to such consumer's mailing address or another mailing address specified by such consumer; or
(B) Making such explanations of benefits available to such consumer by electronic means and notifying such consumer by electronic means, including, but not limited to, electronic mail, when such insurer, center, corporation, society, entity or third-party administrator makes each such explanation of benefits available to such consumer by electronic means, provided making such explanations of benefits available to such consumer by electronic means and notifying such consumer by electronic means complies with all applicable federal and state laws and regulations concerning data security, including, but not limited to, 45 CFR Part 160, as amended from time to time, and 45 CFR Part 164, Subparts A and C, as amended from time to time.
(e) Each method specified by a consumer, in writing, pursuant to subdivision (2) of subsection (d) of this section shall be valid until the consumer submits a written specification to the insurer, center, corporation, society, entity or third-party administrator for a different method. Such insurer, center, corporation, society, entity or third-party administrator shall comply with a written specification under this subsection or subdivision (2) of subsection (d) of this section, as applicable, not later than three business days after such insurer, center, corporation, society, entity or third-party administrator receives such specification.
(f) Each insurer, center, corporation, society, entity or third-party administrator that receives a written specification from a consumer pursuant to subdivision (2) of subsection (d) of this section or subsection (e) of this section, as applicable, shall provide the consumer who made such specification with written confirmation that such insurer, center, corporation, society, entity or third-party administrator received such specification, and advise such consumer, in writing, regarding the status of such specification if such consumer contacts such insurer, center, corporation, society, entity or third-party administrator, in writing, regarding such specification.
(g) Each consumer who is a covered individual under a policy described in subsection (a) of this section and is legally capable of consenting to the provision of covered benefits may specify, in writing, that the insurer, center, corporation, society or entity that delivered, issued for delivery, renewed, amended or continued the policy, or a third-party administrator providing services to such insurer, center, corporation, society or entity, not issue explanations of benefits pursuant to subsections (d) to (f), inclusive, of this section if such explanations of benefits concern covered benefits that were provided to such consumer. Such insurer, center, corporation, society, entity or third-party administrator shall not require such consumer to provide any explanation regarding the basis for such consumer's specification, unless such explanation is required by applicable law or pursuant to an order issued by a court of competent jurisdiction.
(h) Each insurer, center, corporation, society or entity that delivers, issues for delivery, renews, amends or continues a policy described in subsection (a) of this section, and each third-party administrator providing services to such insurer, center, corporation, society or entity, shall disclose to each consumer who is a covered individual under the policy such consumer's ability to submit specifications pursuant to subsections (d) to (g), inclusive, of this section. Such disclosure shall be in plain language and displayed or printed, as applicable, clearly and conspicuously in all evidence of coverage documents, privacy communications, explanations of benefits and Internet web sites that are maintained by such insurer, center, corporation, society, entity or third-party administrator and accessible to consumers in this state.
(i) No insurer, center, corporation, society or entity that is subject to subsections (d) to (h), inclusive, of this section shall require a consumer or policyholder to waive any right to limit disclosure under subsections (d) to (h), inclusive, of this section as a precondition to delivering, issuing for delivery, renewing, amending or continuing a policy described in subsection (a) of this section to the consumer or policyholder. Nothing in this subsection or subsections (d) to (h), inclusive, of this section shall be construed to limit a consumer's or policyholder's ability to request review of an adverse determination.”
(P.A. 15-146, S. 7; P.A. 17-15, S. 43, 44; P.A. 18-41, S. 11; P.A. 21-22, S. 1.)
History: P.A. 15-146 effective January 1, 2016; P.A. 17-15 made technical changes in Subsecs. (a)(2)(D) and (c); P.A. 18-41 amended Subsec. (a)(1) by adding “, accessible” and Subpara. (E) re coverage of noncovered outpatient prescription drugs, effective January 1, 2020; P.A. 21-22 amended Subsec. (a) by dividing existing Subdiv. (1) into Subdivs. (1) and (1)(A), redesignating existing Subdivs. (1)(A) to (1)(E) as Subdivs. (1)(A)(i) to (1)(A)(v), adding new Subdiv. (1)(B) re statement disclosing information re explanations of benefits and making technical and conforming changes, amended Subsec. (b) by adding references to statement and added Subsecs. (d) to (i) re explanations of benefits, disclosures and prohibitions, effective January 1, 2023.