reglab/statecodes huggingface dataset:
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-503b. - Carriers to permit direct access to obstetrician-gynecologist.

(a) As used in this section, “carrier” means each insurer, health care center, hospital service corporation, medical service corporation or other entity delivering, issuing for delivery, renewing, amending or continuing any individual health insurance policy in this state providing coverage of the type specified in subdivisions (1), (2), (4), (10), (11) and (12) of section 38a-469.
(b) Each carrier shall permit a female enrollee direct access to a participating in-network obstetrician-gynecologist for any gynecological examination or care related to pregnancy and shall allow direct access to a participating in-network obstetrician-gynecologist for primary and preventive obstetric and gynecologic services required as a result of any gynecological examination or as a result of a gynecological condition. Such obstetric and gynecologic services include, but are not limited to, pap smear tests. The plan may require the participating in-network obstetrician-gynecologist to discuss such services and any treatment plan with the female enrollee's primary care provider. Nothing in this section shall preclude access to an in-network nurse-midwife as licensed pursuant to sections 20-86c and 20-86g and in-network advanced practice registered nurses as licensed pursuant to sections 20-93 and 20-94a for obstetrical and gynecological services within their scope of practice.
(c) Each carrier may allow a female enrollee to designate either a participating, in-network obstetrician-gynecologist or any other in-network physician designated by the carrier as a primary care provider, or both, and may offer the same choice to all female enrollees.
(P.A. 95-199, S. 1; P.A. 96-227, S. 14; P.A. 01-171, S. 18; P.A. 10-32, S. 120; P.A. 11-19, S. 49; P.A. 14-122, S. 50; P.A. 19-125, S. 10.)
History: P.A. 96-227 amended Subsec. (a) to include Subdiv. (12) in its citation to Sec. 38a-469; P.A. 01-171 amended Subsec. (b) to provide that “such obstetric and gynecologic services include, but are not limited to, pap smear tests”; P.A. 10-32 made a technical change in Subsec. (b), effective May 10, 2010; P.A. 11-19 inserted “or continuing” and made technical changes in Subsec. (a), effective January 1, 2012; P.A. 14-122 made a technical change in Subsec. (b); P.A. 19-125 amended Subsec. (a) to redefine “carrier”, effective January 1, 2020.
See Sec. 38a-530b for similar provisions re group policies.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-503c. - Mandatory coverage for maternity care. Interhospital transfer of newborn infant and mother.

(a) As used in this section, “carrier” means each insurer, health care center, hospital service corporation, medical service corporation or other entity delivering, issuing for delivery, renewing, amending or continuing any individual health insurance policy in this state providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469.
(b) Each individual health insurance carrier that offers maternity benefits shall provide coverage of a minimum of forty-eight hours of inpatient care for a mother and her newborn infant following a vaginal delivery and a minimum of ninety-six hours of inpatient care for a mother and her newborn infant following a caesarean delivery. The time periods shall commence at the time of delivery.
(c) Any decision to shorten the length of inpatient stay to less than that provided under subsection (b) of this section shall be made by the attending health care providers after conferring with the mother.
(d) If a mother and newborn are discharged pursuant to subsection (c) of this section, prior to the inpatient length of stay provided under subsection (b) of this section, coverage shall be provided for a follow-up visit within forty-eight hours of discharge and an additional follow-up visit within seven days of discharge. Such follow-up services shall include, but not be limited to, physical assessment of the newborn, parent education, assistance and training in breast or bottle feeding, assessment of the home support system and the performance of any medically necessary and appropriate clinical tests. Such services shall be consistent with protocols and guidelines developed by attending providers or by national pediatric, obstetric and nursing professional organizations for these services and shall be provided by qualified health care personnel trained in postpartum maternal and newborn pediatric care.
(e) No individual health insurance carrier subject to this section shall require prior authorization for the interhospital transfer of (1) a newborn infant experiencing a life-threatening emergency or condition, or (2) the hospitalized mother of such newborn infant to accompany her newborn infant.
(P.A. 96-177, S. 1, 6; P.A. 11-19, S. 51; P.A. 15-118, S. 52; P.A. 16-162, S. 1.)
History: P.A. 96-177 effective May 24, 1996; P.A. 11-19 inserted “or continuing” and made technical changes in Subsec. (a), effective January 1, 2012; P.A. 15-118 deleted former Subsec. (e) re policyholder notice requirement; P.A. 16-162 added Subsec. (e) re interhospital transfer of newborn infant and mother, effective January 1, 2017.
See Sec. 38a-530c for similar provisions re group policies.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-503d. - Mandatory coverage for mastectomy care. Termination of provider contract prohibited.

(a) 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, amended, renewed or continued in this state shall provide coverage for at least forty-eight hours of inpatient care following a mastectomy or lymph node dissection, and shall provide coverage for a longer period of inpatient care if such care is recommended by the patient's treating physician after conferring with the patient. No such insurance policy may require mastectomy surgery or lymph node dissection to be performed on an outpatient basis. Outpatient surgery or shorter inpatient care is allowable under this section if the patient's treating physician recommends such outpatient surgery or shorter inpatient care after conferring with the patient.
(b) No individual health insurance carrier may terminate the services of, require additional documentation from, require additional utilization review, reduce payments or otherwise penalize or provide financial disincentives to any attending health care provider on the basis that the provider orders care consistent with the provisions of this section.
(P.A. 97-198, S. 1, 5; P.A. 11-19, S. 8.)
History: P.A. 97-198 effective July 1, 1997; P.A. 11-19 made a technical change in Subsec. (a).
See Sec. 38a-530d for similar provisions re group policies.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-504a. - Coverage for routine patient care costs associated with certain clinical trials.

Each individual 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 coverage for the routine patient care costs, as defined in section 38a-504d, associated with clinical trials, in accordance with sections 38a-504b to 38a-504g, inclusive. As used in this section and sections 38a-504b to 38a-504g, inclusive, “clinical trial” means an organized, systematic, scientific study of therapies, tests or other clinical interventions for purposes of treatment or palliation or therapeutic intervention for the prevention of cancer or disabling or life-threatening chronic diseases in human beings.
(P.A. 01-171, S. 8, 25; P.A. 11-19, S. 57; 11-172, S. 1.)
History: P.A. 01-171 effective January 1, 2002; P.A. 11-19 inserted “amended or continued”, redefined “cancer clinical trial” and made a technical change, effective January 1, 2012; P.A. 11-172 inserted “amended or continued”, replaced reference to cancer clinical trials with reference to clinical trials, changed defined term from “cancer clinical trial” to “clinical trial” and redefined same, and made technical changes, effective January 1, 2012.
See Sec. 38a-542a for similar provisions re group policies.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-504b. - Clinical trial criteria.

A clinical trial for the prevention of cancer shall be eligible for coverage only if it involves a therapeutic intervention, is a phase III clinical trial approved by one of the entities identified in this section, and is conducted at multiple institutions. In order to be eligible for coverage of routine patient care costs, as defined in section 38a-504d, a clinical trial shall be (1) conducted under the auspices of an independent peer-reviewed protocol that has been reviewed and approved by: (A) One of the National Institutes of Health; (B) a National Cancer Institute affiliated cooperative group; (C) the federal Food and Drug Administration as part of an investigational new drug or device application or exemption; or (D) the federal Department of Defense or Veterans Affairs; or (2) qualified to receive Medicare coverage of its routine costs under the Medicare Clinical Trial Policy established under the September 19, 2000, Medicare National Coverage Determination, as amended from time to time. Nothing in sections 38a-504a to 38a-504g, inclusive, shall be construed to require coverage for any single institution clinical trial conducted solely under the approval of the institutional review board of an institution, or any trial that is no longer approved by an entity identified in subparagraph (A), (B), (C) or (D) of subdivision (1) of this section.
(P.A. 01-171, S. 9, 25; P.A. 11-19, S. 58; 11-172, S. 2.)
History: P.A. 01-171 effective January 1, 2002; P.A. 11-19 added provision limiting eligibility of clinical trial for the prevention of cancer, effective January 1, 2012; P.A. 11-172 replaced references to cancer clinical trial with references to clinical trial, designated existing clinical trial criteria as Subdiv. (1) and amended same to insert “application or” re investigational new drug or device, added Subdiv. (2) re Medicare qualification, and made technical changes, effective January 1, 2012.
See Sec. 38a-542b for similar provisions re group policies.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-504c. - Evidence and information re eligibility for clinical trial. No coverage required for otherwise reimbursable costs.

In order to be eligible for coverage of routine patient care costs, as defined in section 38a-504d, the insurer, health care center or plan administrator may require that the person or entity seeking coverage for the clinical trial provide: (1) Evidence satisfactory to the insurer, health care center or plan administrator that the insured person receiving coverage meets all of the patient selection criteria for the clinical trial, including credible evidence in the form of clinical or preclinical data showing that the clinical trial is likely to have a benefit for the insured person that is commensurate with the risks of participation in the clinical trial to treat the person's condition; (2) evidence that the appropriate informed consent has been received from the insured person; (3) copies of any medical records, protocols, test results or other clinical information used by the physician or institution seeking to enroll the insured person in the clinical trial; (4) a summary of the anticipated routine patient care costs in excess of the costs for standard treatment; (5) information from the physician or institution seeking to enroll the insured person in the clinical trial regarding those items, including any routine patient care costs, that are eligible for reimbursement by an entity other than the insurer or health care center, including the entity sponsoring the clinical trial; and (6) any additional information that may be reasonably required for the review of a request for coverage of the clinical trial. The health plan or insurer shall request any additional information about a clinical trial not later than five business days after receiving a request for coverage from an insured person or a physician seeking to enroll an insured person in a clinical trial. Nothing in sections 38a-504a to 38a-504g, inclusive, shall be construed to require the insurer or health care center to provide coverage for routine patient care costs that are eligible for reimbursement by an entity other than the insurer, including the entity sponsoring the clinical trial.
(P.A. 01-171, S. 10, 25; P.A. 11-19, S. 59; 11-172, S. 3.)
History: P.A. 01-171 effective January 1, 2002; P.A. 11-19 made technical changes, effective January 1, 2012; P.A. 11-172 replaced references to cancer clinical trial with references to clinical trial and made technical changes, effective January 1, 2012.
See Sec. 38a-542c for similar provisions re group policies.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-504e. - Clinical trials: Billing. Payments.

(a) Providers, hospitals and institutions that provide routine patient care services as set forth in subsection (a) of section 38a-504d as part of a clinical trial that meets the requirements of sections 38a-504a to 38a-504g, inclusive, and is approved for coverage by the insurer or health care center shall not bill the insurer or health care center or the insured person for any facility, ancillary or professional services or costs that are not routine patient care services as set forth in subsection (a) of section 38a-504d or for any product or service that is paid by the entity sponsoring or funding the clinical trial.
(b) Providers, hospitals, institutions and insured persons may appeal a health plan's denials of payment for services only to the extent permitted by the contract between the insurer or health care center and the provider, hospital or institution.
(c) Providers, hospitals or institutions that have contracts with the insurer or health care center to render covered routine patient care services to insured persons as part of a clinical trial shall not bill the insured person for the cost of any covered routine patient care service.
(d) Providers, hospitals or institutions that do not have a contract with the insurer or health care center to render covered routine patient care services to insured persons as part of a clinical trial shall not bill the insured person for the cost of any covered routine patient care service.
(e) Nothing in this section shall be construed to prohibit a provider, hospital or institution from collecting a deductible or copayment as set forth in the insured person's contract for any covered routine patient care service.
(f) Pursuant to subsection (b) of section 38a-504d, insurers or health care centers shall be required to pay providers, hospitals and institutions that do not have a contract with the insurer or health care center to render covered routine patient care services to insured persons the lesser of (1) the lowest contracted per diem, fee schedule rate or case rate that the insurer or health care center pays to any participating provider in the state of Connecticut for similar in-network services, or (2) the billed charges. Providers, hospitals or institutions shall not collect any amount more than the total amount paid by the insurer or health care center and the insured person in the form of a deductible or copayment set forth in the insured person's contract. Such amount shall be deemed by the provider, hospital or institution to be payment in full.
(P.A. 01-171, S. 12, 25; P.A. 11-172, S. 5.)
History: P.A. 01-171 effective January 1, 2002; P.A. 11-172 replaced references to cancer clinical trial with references to clinical trial and, in Subsecs. (c), (d) and (f), changed “may not” to “shall not”, effective January 1, 2012.
See Sec. 38a-542e for similar provisions re group policies.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-504g. - Clinical trials: Submission and certification of policy forms.

(a) Any insurer or health care center with coverage policies for care in clinical trials shall submit such policies to the Insurance Department for evaluation and approval. The department shall certify whether the insurer's or health care center's coverage policy for routine patient care costs associated with clinical trials is substantially equivalent to the requirements of sections 38a-504a to 38a-504f, inclusive. If the department finds that such coverage is substantially equivalent to the requirements of sections 38a-504a to 38a-504f, inclusive, the insurer or health care center shall be exempt from the provisions of sections 38a-504a to 38a-504f, inclusive.
(b) Any such insurer or health care center shall report annually, in writing, to the department that there have been no changes in the policy as certified by the department. If there has been any change in the policy, the insurer or health care center shall resubmit its policy for certification by the department.
(c) Any insurer or health care center coverage policy found by the department not to be substantially equivalent to the requirements of sections 38a-504a to 38a-504f, inclusive, shall abide by the requirements of sections 38a-504a to 38a-504f, inclusive, until the insurer or health care center has received such certification by the department.
(P.A. 01-171, S. 14, 25; P.A. 11-172, S. 7; P.A. 12-145, S. 16.)
History: P.A. 01-171 effective January 1, 2002; P.A. 11-172 replaced references to cancer clinical trials with references to clinical trials in Subsec. (a), effective January 1, 2012; P.A. 12-145 replaced references to Sec. 38a-504g with references to Sec. 38a-504f, effective June 15, 2012.
See Sec. 38a-542g for similar provisions re group policies.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-506. (Formerly Sec. 38-173). - Penalty.

Any insurer, hospital service corporation, medical service corporation, health care center or fraternal benefit society, or any officer or agent thereof, delivering or issuing for delivery to any person in this state any policy in violation of any of the provisions of sections 38a-481 to 38a-488, inclusive, shall be fined not more than ten thousand dollars for each offense, and the commissioner may revoke the license of any foreign or alien insurer, or any agent thereof, violating any of said provisions.
(1949 Rev., S. 6189; 1951, S. 2843d; P.A. 90-243, S. 95; P.A. 08-178, S. 16; P.A. 15-118, S. 9.)
History: P.A. 90-243 applied provisions to hospital or medical service corporations, health care centers, and fraternal benefit societies and substituted “foreign” for “nonresident” and “alien” for “foreign” insurance companies; Section 38-173 transferred to Sec. 38a-506 in 1991; P.A. 08-178 increased maximum fine from $500 to $10,000 per offense; P.A. 15-118 made a technical change.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-507. - Coverage for services performed by chiropractors.

Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6) and (11) of section 38a-469, delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for services rendered by a chiropractor licensed under chapter 372 to the same extent coverage is provided for services rendered by a physician, if such chiropractic services (1) treat a condition covered under such policy, and (2) are within those services a chiropractor is licensed to perform.
(P.A. 89-112; P.A. 90-243, S. 176; P.A. 11-19, S. 55; P.A. 17-15, S. 97.)
History: P.A. 90-243 substituted “health insurance policy” for “group hospital”, “medical expense insurance policy” and “individual or group hospital or medical service plan” and deleted references to “contract”; P.A. 11-19 inserted “amended or continued” and made technical changes, effective January 1, 2012; P.A. 17-15 added “providing coverage of the type specified in subdivisions (1), (2), (4), (6) and (11) of section 38a-469,”.
See Sec. 38a-534 for similar provisions re group policies.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-508. - Coverage for adopted children.

(a) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state shall provide coverage for a child legally placed for adoption with the insured or subscriber who is an adoptive parent or a prospective adoptive parent, even though the adoption has not been finalized, provided the child lives in the household of such insured or subscriber and the child is dependent upon such person for support and maintenance.
(b) Coverage for such child legally placed for adoption shall consist of coverage for injury and sickness including necessary care and treatment of medically diagnosed congenital defects and birth abnormalities within the limits of the policy.
(c) If payment of a specific premium or subscription fee is required to provide coverage for a child legally placed for adoption with the insured or subscriber who is an adoptive parent or a prospective adoptive parent, the policy or contract may require that notification of acceptance of such child and payment of the required premium or fees be furnished to the insurer, hospital service corporation, medical service corporation or health care center within thirty-one days after the acceptance of such child in order to continue coverage beyond such thirty-one-day period, provided failure to furnish such notice or pay such premium or fees shall not prejudice any claim originating within such thirty-one-day period.
(d) Such policy (1) shall cover such child legally placed for adoption on the same basis as other dependents, and (2) may not contain any provision concerning preexisting conditions, insurability, eligibility or health underwriting approval for a child legally placed for adoption, except that an insurer, hospital service corporation, medical service corporation or health care center may require health underwriting for a child legally placed for adoption if a required premium or subscription fee and completed application materials are not provided to the insurer, hospital service corporation, medical service corporation or health care center before the expiration of the thirty-one-day period following the date the child was legally placed for adoption.
(P.A. 91-97, S. 1; P.A. 02-96, S. 1; P.A. 03-70, S. 1; P.A. 15-118, S. 10.)
History: P.A. 02-96 amended Subsec. (a) to substitute “each” for “every” and “amended, renewed or continued in this state” for “amended or renewed in this state on or after October 1, 1991,” and added Subsec. (d) re coverage and prohibited provisions; P.A. 03-70 amended Subsec. (d) to add exception re health underwriting if required premium or subscription fee and completed application materials are not provided before expiration of thirty-one-day period; P.A. 15-118 made technical changes in Subsecs. (c) and (d).
See Sec. 38a-549 for similar provisions re group policies.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-510a. - Prescription drug coverage. Synchronized refills.

No individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11), (12) and (16) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state that provides coverage for prescription drugs shall deny coverage for the refill of any drug prescribed for the treatment of a chronic illness that is made in accordance with a plan among the insured, a practitioner and a pharmacist to synchronize the refilling of multiple prescriptions for the insured.
(P.A. 13-131, S. 1.)
History: P.A. 13-131 effective January 1, 2014.
See Sec. 38a-544a for similar provisions re group policies.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-510b. - Prescription drug coverage. Prior authorization for naloxone hydrochloride or similar drug not required.

No individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11), (12) and (16) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state that provides coverage for prescription drugs and includes on its formulary naloxone hydrochloride or any other similarly acting and equally safe drug approved by the federal Food and Drug Administration for the treatment of drug overdose shall require prior authorization for such drug.
(P.A. 16-43, S. 2.)
History: P.A. 16-43 effective January 1, 2017.
See Sec. 38a-544b for similar provisions re group policies.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-510c. - Coverage for investigational drug, biological product or device for insureds with terminal illnesses. Liability of health carrier.

(a) As used in this section, “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 insurance policy providing coverage of the type provided in subdivisions (1), (2), (4), (11), (12) and (16) of section 38a-469 in this state.
(b) A health carrier may provide coverage for an investigational drug, biological product or device, as defined in section 20-14q, that is made available pursuant to section 21a-70g to an insured patient who is eligible under subsection (b) of section 20-14q.
(c) A health carrier may deny coverage to an insured patient from the time such patient begins treatment with the investigational drug, biological product or device for a period not to exceed six months from the date such patient ceases treatment with the investigational drug, biological product or device, except that coverage may not be denied for a preexisting condition or for coverage for benefits that commenced prior to the date such patient begins such treatment.
(d) Nothing in this section shall affect the provisions of sections 38a-504a to 38a-504g, inclusive, and 38a-542a to 38a-542g, inclusive, concerning insurance coverage for certain costs associated with clinical trials. Treatment with an investigational drug, biological product or device shall be deemed to constitute the practice of medicine and shall not be considered a clinical trial for the purposes of said sections.
(e) Nothing in this section shall create a cause of action against a health carrier that provides coverage for an investigational drug, biological product or device pursuant to subsection (b) of this section, or denies coverage in accordance with subsection (c) of this section, to an insured patient who begins treatment with an investigational drug, biological product or device.
(P.A. 16-214, S. 3.)
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-511. - Copayments re in-network imaging services.

(a) No health insurer, health care center, hospital service corporation, medical service corporation or fraternal benefit society that provides coverage under an individual health insurance policy or contract for magnetic resonance imaging or computed axial tomography may (1) require total copayments in excess of three hundred seventy-five dollars for all such in-network imaging services combined annually, or (2) require a copayment in excess of seventy-five dollars for each in-network magnetic resonance imaging or computed axial tomography, provided the physician ordering the radiological services and the physician rendering such services are not the same person or are not participating in the same group practice.
(b) No health insurer, health care center, hospital service corporation, medical service corporation or fraternal benefit society that provides coverage under an individual health insurance policy or contract for positron emission tomography may (1) require total copayments in excess of four hundred dollars for all such in-network imaging services combined annually, or (2) require a copayment in excess of one hundred dollars for each in-network positron emission tomography, provided the physician ordering the radiological service and the physician rendering such service are not the same person or are not participating in the same group practice.
(c) The provisions of subsections (a) and (b) of this section shall not apply to a high deductible health plan as that term is used in subsection (f) of section 38a-493.
(P.A. 06-180, S. 1; 07-54, S. 3; P.A. 10-5, S. 25; P.A. 18-68, S. 14; July Sp. Sess. P.A. 20-4, S. 25.)
History: P.A. 07-54 made technical changes in Subsecs. (a) and (b), effective May 22, 2007; P.A. 10-5 replaced reference to Sec. 38a-520 with reference to Sec. 38a-493 in Subsec. (c), effective May 5, 2010; P.A. 18-68 made a technical change in Subsec. (c); July Sp. Sess. P.A. 20-4 amended Subsec. (c) by substituting “high deductible health plan” for “high deductible plan”.
See Sec. 38a-550 for similar provisions re group policies.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-511a. - Copayments re in-network physical therapy services and in-network occupational therapy services.

No individual 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 impose copayments that exceed a maximum of thirty dollars per visit for in-network (1) physical therapy services rendered by a physical therapist licensed under section 20-73, or (2) occupational therapy services rendered by an occupational therapist licensed under section 20-74b or 20-74c.
(P.A. 13-307, S. 1; P.A. 14-97, S. 3.)
History: P.A. 13-307 effective January 1, 2015; P.A. 14-97 designated existing provisions re copayment limit for physical therapy services as Subdiv. (1) and added Subdiv. (2) re copayment limit for occupational therapy services, effective January 1, 2015.
See Sec. 38a-550a for similar provisions re group policies.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-512. - Applicability of statutes to certain major medical expense policies.

Any policy providing major medical expense coverage that is written to complement underlying hospital, medical and surgical expense coverage shall not be required, unless otherwise specifically provided, to include the benefits required in the underlying hospital, medical and surgical expense coverage. Except as otherwise provided in this title, the provisions of sections 38a-513, 38a-529, 38a-532, 38a-545 and 38a-547 shall not apply to any subscriber contract issued by a health care center.
(P.A. 90-243, S. 96; P.A. 03-199, S. 6; P.A. 15-118, S. 68.)
History: P.A. 03-199 deleted provision re inapplicability of Sec. 38a-546 to subscriber contracts issued by a health care center; P.A. 15-118 added “Except as otherwise provided in this title,” and made technical changes.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-512b. - Termination of coverage of child, stepchild or other dependent child in group policies. Dental or vision coverage.

(a) Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state shall provide that coverage of a child, stepchild or other dependent child shall terminate not earlier than the policy anniversary date after the date on which the child, stepchild or other dependent child attains the age of twenty-six.
(b) Each group health insurance policy described in subsection (a) of this section, and each group health insurance policy providing coverage of the type specified in subdivision (16) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state, that includes or provides dental or vision coverage shall provide that dental or vision coverage of a child, stepchild or other dependent child shall terminate not earlier than the policy anniversary date after the date on which the child, stepchild or other dependent child attains the age of twenty-six.
(c) Each policy subject to this section shall cover a stepchild or other dependent child on the same basis as a biological child.
(P.A. 11-58, S. 38; P.A. 21-149, S. 2.)
History: P.A. 11-58 effective July 2, 2011; P.A. 21-149 designated existing provisions re health insurance coverage for child as Subsec. (a) and amended same to add references to stepchild or other dependent child, delete provision re child becoming covered under group health plan through dependent's employment, and make technical and conforming changes, added Subsec. (b) re provisions re policy providing single ancillary dental or vision coverage, and designated existing provision requiring coverage of stepchild on same basis as biological child as Subsec. (c) and amended same to add reference to other dependent child and make technical changes, effective January 1, 2022.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-512c. - Annual and lifetime limits.

(a) No 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, amended, renewed or continued in this state shall include an annual or lifetime limit on the dollar value of benefits for a covered individual, for covered benefits that are essential health benefits, as defined in (1) the Patient Protection and Affordable Care Act, P.L. 111-148, as amended from time to time, or regulations adopted thereunder, or (2) section 38a-518q, or regulations adopted thereunder.
(b) This section shall not prohibit the inclusion of a lifetime limit on specific covered benefits that are not essential health benefits, provided the lifetime limit for reasonable charges or, when applicable, the allowance agreed upon by a health care provider and an insurer, health care center, hospital service corporation, medical service corporation or fraternal benefit society for charges actually incurred for any specific covered benefit, shall be not less than one million dollars per covered individual.
(P.A. 11-58, S. 43; P.A. 17-15, S. 59; P.A. 18-10, S. 10.)
History: P.A. 11-58 effective July 2, 2011; P.A. 17-15 made a technical change in Subsec. (a); P.A. 18-10 amended Subsec. (a) by designating existing provisions re Affordable Care Act as Subdiv. (1), and adding Subdiv. (2) re Sec. 38a-518q and regulations adopted thereunder, effective January 1, 2019.
See Sec. 38a-482c for similar provisions re individual policies.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-513a. - Time limits for coverage determinations. Notice requirements.

Section 38a-513a is repealed, effective October 1, 2015.
(P.A. 99-284, S. 13; P.A. 10-24, S. 2; P.A. 11-19, S. 24; P.A. 15-118, S. 71.)
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-513b. - Coverage and notice re experimental treatments. Appeals.

(a) Each group health insurance policy delivered, issued for delivery, renewed, amended or continued in this state shall define the extent to which it provides coverage for experimental treatments.
(b) No such health insurance policy may deny a procedure, treatment or the use of any drug as experimental if such procedure, treatment or drug, for the illness or condition being treated, or for the diagnosis for which it is being prescribed, has successfully completed a phase III clinical trial of the federal Food and Drug Administration.
(c) Any person who has been diagnosed with a condition that creates a life expectancy in that person of less than two years and who has been denied an otherwise covered procedure, treatment or drug on the grounds that it is experimental may request an expedited appeal as provided in section 38a-591e and may appeal a denial thereof to the Insurance Commissioner in accordance with the procedures established in section 38a-591g.
(P.A. 99-284, S. 16, 60; P.A. 11-58, S. 82; P.A. 12-145, S. 44.)
History: P.A. 99-284 effective January 1, 2000; P.A. 11-58 amended Subsec. (c) to replace references to Secs. 38a-226c and 38a-478n with “section 38a-591e” and “section 38a-591g”, respectively, and deleted former Subsec. (d) re appeal of a procedure, treatment or drug denied on grounds that such procedure, treatment or drug is experimental, effective July 1, 2011; P.A. 12-145 amended Subsec. (a) to delete “on or after January 1, 2000”, effective June 15, 2012.
See Sec. 38a-483c for similar provisions re individual policies.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-513c. - Group health insurance policy to contain definition of “medically necessary” or “medical necessity”.

(a) No insurer, health care center, hospital service corporation, medical service corporation or other entity delivering, issuing for delivery, renewing, continuing or amending any group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469 in this state shall deliver or issue for delivery in this state any such policy unless such policy contains a definition of “medically necessary” or “medical necessity” as follows: “Medically necessary” or “medical necessity” means health care services that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are: (1) In accordance with generally accepted standards of medical practice; (2) clinically appropriate, in terms of type, frequency, extent, site and duration and considered effective for the patient's illness, injury or disease; and (3) not primarily for the convenience of the patient, physician or other health care provider and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness, injury or disease. For the purposes of this subsection, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community or otherwise consistent with the standards set forth in policy issues involving clinical judgment.
(b) The provisions of subsection (a) of this section shall not apply to any insurer, health care center, hospital service corporation, medical service corporation or other entity that has entered into any national settlement agreement until the expiration of any such agreement.
(P.A. 07-75, S. 2; P.A. 11-19, S. 22.)
History: P.A. 07-75 effective January 1, 2008; P.A. 11-19 made technical changes.
See Sec. 38a-482a for similar provisions re individual policies.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-513d. - Insurers prohibited from issuing policy with limited coverage to employer as replacement for a comprehensive health insurance plan. Disclosure required in policy providing limited coverage. Limited coverage defined.

(a) No insurer, health care center, hospital service corporation, medical service corporation or other entity delivering, issuing for delivery, renewing, continuing or amending any group health insurance policy in this state on or after January 1, 2008, shall deliver or issue for delivery in this state any policy providing limited coverage to any employer as a replacement for a comprehensive health insurance plan for its employees.
(b) Each group health insurance policy, subscriber contract or certificate of coverage delivered or issued for delivery in this state on or after January 1, 2008, that provides limited coverage, and any marketing material, application for coverage and enrollment material relative to such policy, contract or certificate, shall include the following statement printed in capital letters in not less than twelve-point boldface type and located in a conspicuous manner on such document:
“THIS LIMITED HEALTH BENEFITS PLAN DOES NOT PROVIDE COMPREHENSIVE MEDICAL COVERAGE. IT IS A BASIC OR LIMITED BENEFITS POLICY AND IS NOT INTENDED TO COVER ALL MEDICAL EXPENSES. THIS PLAN IS NOT DESIGNED TO COVER THE COSTS OF SERIOUS OR CHRONIC ILLNESS. IT CONTAINS SPECIFIC DOLLAR LIMITS THAT WILL BE PAID FOR MEDICAL SERVICES WHICH MAY NOT BE EXCEEDED. IF THE COST OF SERVICES EXCEEDS THOSE LIMITS, THE BENEFICIARY AND NOT THE INSURER IS RESPONSIBLE FOR PAYMENT OF THE EXCESS AMOUNTS. THE SPECIFIC DOLLAR LIMITS ARE AS FOLLOWS: (INSURER TO SPECIFY SUCH AMOUNTS).”
(c) For the purposes of this section, “limited coverage” means an insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 that contains an annual maximum benefit of less than one hundred thousand dollars or fixed dollar benefits of less than twenty thousand dollars on any core services. For the purpose of this section, “core services” means medical, surgical and hospital services, including inpatient and outpatient physician, laboratory and imaging services.
(P.A. 07-96, S. 2; P.A. 08-147, S. 12.)
History: P.A. 07-96 effective July 1, 2007; P.A. 08-147 redefined “limited coverage” in Subsec. (c) to specify fixed dollar benefits of less than $20,000 on any core services.
See Sec. 38a-482b for similar provisions re individual policies.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-513g. - Employer submission of plan cost information to Comptroller.

(a) For the purposes of this section, “employer” has the same meaning as provided in section 38a-513f.
(b) Not later than October first, annually, each employer that sponsors a fully insured group health insurance policy for its active employees, early retirees and retirees that provides coverage of the type specified in subdivisions (1), (2), (4), (11), (12) and (16) of section 38a-469 shall submit electronically to the Comptroller, in a form prescribed by the Comptroller, the following information: For the two policy years immediately preceding, the percentage increase or decrease in the policy or plan costs, calculated as the total premium costs, inclusive of any premiums or contributions paid by active employees, early retirees and retirees, divided by the total number of active employees, early retirees and retirees covered by such policy.
(P.A. 11-58, S. 9.)
History: P.A. 11-58 effective July 1, 2011.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-514a. - Biologically-based mental illness. Coverage required.

Section 38a-514a is repealed, effective January 1, 2000.
(P.A. 97-99, S. 27; June 18 Sp. Sess. P.A. 97-8, S. 62, 88; P.A. 99-284, S. 59, 60.)
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-514c. - Mental health and substance use disorder benefits. Nonquantitative treatment limitations.

No 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 on or after January 1, 2020, shall apply a nonquantitative treatment limitation to mental health and substance use disorder benefits unless such policy applies such limitation to such benefits in a manner that is comparable to, and not more stringent than, the manner in which such policy applies such limitation to medical and surgical benefits. For the purposes of this section, “nonquantitative treatment limitation” and “mental health and substance use disorder benefits” have the same meaning as provided in section 38a-477ee.
(P.A. 19-159, S. 3.)
History: P.A. 19-159 effective January 1, 2020.
See Sec. 38a-488c for similar provisions re individual policies.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-514d. - Coverage for substance abuse services provided pursuant to court order.

No group 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 on or after January 1, 2020, shall deny coverage for covered substance abuse services solely because such substance abuse services were provided pursuant to an order issued by a court of competent jurisdiction.
(P.A. 19-159, S. 5.)
History: P.A. 19-159 effective January 1, 2020.
See Sec. 38a-488d for similar provisions re individual policies.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-514f. - Coverage for services provided under the Collaborative Care Model.

(a) For the purposes of this section:
(1) “Collaborative Care Model” means the integrated delivery of behavioral health and primary care services by a primary care team that includes a primary care provider, a behavioral care manager, a psychiatric consultant and a database used by the behavioral care manager to track patient progress;
(2) “CPT code” means a code number under the Current Procedural Terminology system developed by the American Medical Association; and
(3) “HCPCS code” means a code number under the Healthcare Common Procedure Coding System developed by the federal Centers for Medicare and Medicaid Services.
(b) Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 and delivered, issued for delivery, renewed, amended or continued in this state on or after January 1, 2023, shall provide coverage for health care services that a primary care provider provides to an insured under the Collaborative Care Model. Such services shall include, but need not be limited to, services with a CPT code of 99484, 99492, 99493 or 99494 or HCPCS code of G2214, or any subsequent corresponding code.
(P.A. 22-47, S. 48.)
History: P.A. 22-47 effective January 1, 2023.