reglab/statecodes huggingface dataset:
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-477e. - Health carriers to maintain Internet web site and toll-free telephone number. Available information. Exception.

(a) On and after January 1, 2017, each health carrier, as defined in section 19a-755b, shall maintain an Internet web site and toll-free telephone number that enables consumers to request and obtain: (1) Information on in-network costs for inpatient admissions, health care procedures and services, including (A) the allowed amount for, at a minimum, admissions and procedures reported to the executive director of the Office of Health Strategy pursuant to section 19a-755b for each health care provider in the state; (B) the estimated out-of-pocket costs that a consumer would be responsible for paying for any such admission or procedure that is medically necessary, including any facility fee, coinsurance, copayment, deductible or other out-of-pocket expense; and (C) data or other information concerning (i) quality measures for the health care provider, (ii) patient satisfaction, to the extent such information is available, (iii) a directory of participating providers, as defined in section 38a-472f, in accordance with the provisions of section 38a-477h; and (2) information on out-of-network costs for inpatient admissions, health care procedures and services.
(b) A health carrier shall advise the consumer when providing the information on out-of-pocket costs that the amounts are estimates and that the consumer's actual cost may vary due to health care provider contractual changes, the need for unforeseen services that arise out of the proposed admission or procedure or other circumstances.
(c) The provisions of this section shall not apply to a health carrier with less than forty thousand covered lives in the state. If in any year, a health carrier exceeds forty thousand covered lives in the state, the provisions of this section shall begin to apply on January first in the following year.
(P.A. 15-146, S. 5; P.A. 16-77, S. 3; 16-205, S. 5; P.A. 17-15, S. 45; June Sp. Sess. P.A. 17-2, S. 123; P.A. 18-91, S. 6.)
History: P.A. 16-77 amended Subsec. (a) by replacing “July 1, 2016” with “January 1, 2017”, and added Subsec. (c) re health carriers to which provisions of section do not apply, effective June 2, 2016; P.A. 16-205 amended Subsec. (a) by adding reference to Sec. 38a-1084a, deleting former Subdiv. (1)(C)(iii) to (1)(C)(v) and adding new Subdiv. (1)(C)(iii) re directory of participating providers, effective January 1, 2017; P.A. 17-15 amended Subsec. (a)(1)(C)(iii) by replacing reference to Sec. 38a-472f with reference to Sec. 38a-477h; June Sp. Sess. P.A. 17-2 amended Subsec. (a) by replacing “38a-1084a” with “19a-755b”, effective October 31, 2017; P.A. 18-91 amended Subsec. (a) by replacing “exchange” with “executive director of the Office of Health Strategy”, effective May 14, 2018.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-477f. - Contract provision prohibiting certain disclosures prohibited.

(a) On and after January 1, 2016, no contract entered into or renewed between a health care provider and a health carrier shall contain a provision prohibiting disclosure of (1) billed or allowed amounts, reimbursement rates or out-of-pocket costs, or (2) any data to the all-payer claims database program established under section 19a-755a. Information described in subdivisions (1) and (2) of this subsection may be used to assist consumers and institutional purchasers in making informed decisions regarding their health care and informed choices among health care providers and allow comparisons between prices paid by various health carriers to health care providers.
(b) On and after October 1, 2017, no contract entered into between a health care provider, or any agent or vendor retained by the health care provider to provide data or analytical services to evaluate and manage health care services provided to the health carrier's plan participants, and a health carrier shall contain a provision prohibiting disclosure of (1) billed or allowed amounts, reimbursement rates or out-of-pocket costs, or (2) any data to the all-payer claims database program established under section 19a-755a. Information described in subdivisions (1) and (2) of this subsection may be used to assist consumers and institutional purchasers in making informed decisions regarding their health care and informed choices among health care providers and allow comparisons between prices paid by various health carriers to health care providers.
(c) If a contract described in subsection (a) or (b) of this section, whichever is applicable, contains a provision prohibited under the applicable subsection, such provision shall be void and unenforceable. The invalidity or unenforceability of any contract provision under this subsection shall not affect any other provision of the contract.
(P.A. 15-146, S. 4; P.A. 17-241, S. 3; June Sp. Sess. P.A. 17-2, S. 122.)
History: P.A. 17-241 designated existing provisions re contract entered into on and after January 1, 2016 between health care provider and health carrier as Subsec. (a) and amending same to replace “and (2)” with “or (2)”, and replace “for the purpose of assisting” with “information described in subdivisions (1) and (2) of this subsection may be used to assist”, added Subsec. (b) re contract entered into on and after October 1, 2017 between health care provider, or its agent or vendor, and health carrier, and added Subsec. (c) re contract provisions prohibited under subsection to be void and unenforceable; June Sp. Sess. P.A. 17-2 amended Subsecs. (a)(2) and (b)(2) by replacing “38a-1091” with “19a-755a”, effective October 31, 2017.
See Sec. 19a-755b re applicable definitions.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-477ff. - Third-party discounts and payments for covered benefits. Credit required.

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 an individual or group health insurance policy in this state on or after January 1, 2022, providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 shall, when calculating an insured's liability for a coinsurance, copayment, deductible or other out-of-pocket expense for a covered benefit, give credit for any discount provided or payment made by a third party for the amount of, or any portion of the amount of, the coinsurance, copayment, deductible or other out-of-pocket expense for the covered benefit.
(P.A. 21-14, S. 2.)
History: P.A. 21-14 effective January 1, 2022.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-477gg. - Contracts between health carriers and pharmacy benefits managers. Credit required for third-party discounts and payments for covered prescription drug benefits.

On and after January 1, 2022, each contract entered into between a health carrier, as defined in section 38a-591a, and a pharmacy benefits manager, as defined in section 38a-479aaa, for the administration of the pharmacy benefit portion of a health benefit plan in this state on behalf of plan sponsors shall require that the pharmacy benefits manager, when calculating an insured's or enrollee's liability for a coinsurance, copayment, deductible or other out-of-pocket expense for a covered prescription drug benefit, give credit for any discount provided or payment made by a third party for the amount of, or any portion of the amount of, the coinsurance, copayment, deductible or other out-of-pocket expense for the covered prescription drug benefit.
(P.A. 21-14, S. 5.)
History: P.A. 21-14 effective January 1, 2022.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-477hh. - Denial of coverage for otherwise covered benefits based on measurement of blood oxygen level by pulse oximeter prohibited.

No insurer, health care center, hospital service corporation, medical service corporation, fraternal benefit society or other entity delivering, issuing for delivery, renewing, amending or continuing an individual or group health insurance policy in this state on or after January 1, 2022, providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 shall deny coverage for an otherwise covered benefit if such denial is exclusively based on an insured's blood oxygen level as measured by a pulse oximeter.
(P.A. 21-57, S. 2.)
History: P.A. 21-57 effective January 1, 2022.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-477ii. - Pulse oximeter accuracy. Educational materials. Distribution and posting required.

(a) For the purposes of this section:
(1) “Health carrier” has the same meaning as provided in section 38a-1080; and
(2) “Pharmacy benefits manager” has the same meaning as provided in section 38a-479aaa.
(b) Not later than July 1, 2022, the Insurance Department shall:
(1) Post the educational materials developed pursuant to subsection (b) of section 19a-133d on the department's Internet web site; and
(2) Distribute the educational materials developed pursuant to subsection (b) of section 19a-133d to each health carrier and pharmacy benefits manager doing business in this state.
(P.A. 21-57, S. 3.)
History: P.A. 21-57 effective July 1, 2021.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-477kk. - Proof of coverage to disclose whether coverage is fully insured or self-insured. Regulations.

(a) For the purposes of this section:
(1) “Health carrier” has the same meaning as provided in section 38a-1080; and
(2) “Third-party administrator” has the same meaning as provided in section 38a-720.
(b) Each health carrier or third-party administrator that issues a card to an individual in this state for the purpose of enabling such individual to prove that such individual has health coverage shall include in such card a statement disclosing whether such coverage is fully insured or self-insured. Such statement shall be prominently displayed on such card in a readily understandable, standardized form prescribed by the Insurance Commissioner.
(c) The Insurance Commissioner may adopt regulations, in accordance with the provisions of chapter 54, to implement the provisions of this section.
(June Sp. Sess. P.A. 21-2, S. 313.)
History: June Sp. Sess. P.A. 21-2 effective January 1, 2022.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-477ll. - Coverage for health enhancement programs.

(a) For the purposes of this section, “health enhancement program” means a health benefit program that ensures access and removes barriers to essential, high-value clinical services.
(b) (1) Not later than January 1, 2024, 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 in this state an individual or group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 shall develop not less than two health enhancement programs under such policy.
(2) Each health enhancement program developed pursuant to subdivision (1) of this subsection shall:
(A) Be available to each insured under the individual or group health insurance policy; and
(B) Provide to each insured under the individual or group health insurance policy incentives that are directly related to the provision of health insurance coverage, provided such insured chooses to complete certain preventive examinations and screenings recommended by the United States Preventive Services Task Force with a rating of “A” or “B”.
(3) No health enhancement program developed pursuant to subdivision (1) of this subsection shall impose any penalty or other negative incentive on an insured under the individual or group health insurance policy nor shall any insured be required to participate in a health enhancement program.
(c) 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 include coverage for the health enhancement programs that the insurer, health care center, hospital service corporation, medical service corporation, fraternal benefit society or other entity that delivered, issued, renewed, amended or continued such policy developed pursuant to this section.
(d) 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 include coverage for the health enhancement programs that the insurer, health care center, hospital service corporation, medical service corporation, fraternal benefit society or other entity that delivered, issued, renewed, amended or continued such policy developed pursuant to this section.
(e) The Insurance Commissioner may adopt regulations, in accordance with the provisions of chapter 54, to implement the provisions of this section.
(P.A. 22-118, S. 224.)
History: P.A. 22-118 effective January 1, 2023.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-478a. - Commissioner's report to the Governor and the General Assembly.

On March first annually, the Insurance Commissioner shall submit a report to the Governor and to the joint standing committees of the General Assembly having cognizance of matters relating to public health and insurance, concerning the commissioner's responsibilities under the provisions of sections 38a-478 to 38a-478u, inclusive, 38a-479aa, 38a-591a to 38a-591h, inclusive, and 38a-993. The report shall include: (1) A summary of the quality assurance plans submitted by managed care organizations pursuant to section 38a-478c along with suggested changes to improve such plans; (2) suggested modifications to the consumer report card developed under the provisions of section 38a-478l; (3) a summary of the commissioner's procedures and activities in conducting market conduct examinations of utilization review companies and preferred provider networks, including, but not limited to: (A) The number of desk and field audits completed during the previous calendar year; (B) a summary of findings of the desk and field audits, including any recommendations made for improvements or modifications; (C) a description of complaints concerning managed care companies, and any preferred provider network that provides services to enrollees on behalf of the managed care organization, including a summary and analysis of any trends or similarities found in the managed care complaints filed by enrollees; (4) a summary of the complaints concerning managed care organizations received by the Insurance Department's Consumer Affairs Division and the commissioner under section 38a-591g, including a summary and analysis of any trends or similarities found in the complaints received; (5) a summary of any violations the commissioner has found against any managed care organization or any preferred provider network that provides services to enrollees on behalf of the managed care organization; and (6) a summary of the issues discussed related to health care or managed care organizations at the Insurance Department's quarterly forums throughout the state.
(P.A. 97-99, S. 2; June 18 Sp. Sess. P.A. 97-8, S. 57, 88; P.A. 99-284, S. 51, 60; P.A. 00-196, S. 22; June Sp. Sess. P.A. 01-4, S. 23; P.A. 03-169, S. 11; P.A. 11-58, S. 70.)
History: June 18 Sp. Sess. P.A. 97-8 changed reporting date from January 15, 1999, to March 1, 1999, and in Subdiv. (3)(C) changed “complaints” to “managed care complaints”, effective July 1, 1997; P.A. 99-284 deleted obsolete reference to Sec. 38a-514a, effective January 1, 2000; P.A. 00-196 made a technical change; June Sp. Sess. P.A. 01-4 replaced reference to Sec. 19a-647 with reference to Sec. 38a-479aa; P.A. 03-169 added provisions re preferred provider networks in Subdivs. (3) and (5); P.A. 11-58 replaced references to Secs. 38a-226 to 38a-226d and 38a-478n with “sections 38a-591a to 38a-591h, inclusive,” and “section 38a-591g”, respectively, added “concerning managed care organizations” in Subdiv. (4), and made technical changes, effective July 1, 2011.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-478b. - Penalty for managed care organization's failure to file data and reports. Commissioner's report to the Governor and the General Assembly on organizations that fail to file data and reports.

(a) Each managed care organization, as defined in section 38a-478, that fails to file the data, reports or information required by sections 38a-478 to 38a-478u, inclusive, 38a-479aa, 38a-591a to 38a-591h, inclusive, and 38a-993 shall pay a late fee of one hundred dollars per day for each day from the due date of such data, reports or information to the date of filing. Each managed care organization that files incomplete data, reports or information shall be so informed by the commissioner, shall be given a date by which to remedy such incomplete filing and shall pay said late fee commencing from the new due date.
(b) On June first annually, the commissioner shall submit to the Governor and to the joint standing committees of the General Assembly having cognizance of matters relating to public health and insurance, a list of those managed care organizations that have failed to file any data, report or information required by sections 38a-478 to 38a-478u, inclusive, 38a-479aa, 38a-591a to 38a-591h, inclusive, and 38a-993.
(P.A. 97-99, S. 3; P.A. 99-284, S. 52, 60; P.A. 00-196, S. 23; June Sp. Sess. P.A. 01-4, S. 24; P.A. 11-58, S. 71.)
History: P.A. 99-284 deleted obsolete references to Sec. 38a-514a, effective January 1, 2000; P.A. 00-196 made a technical change in Subsec. (b); June Sp. Sess. P.A. 01-4 replaced references to Sec. 19a-647 with references to Sec. 38a-479aa; P.A. 11-58 replaced references to Secs. 38a-226 to 38a-226d with “sections 38a-591a to 38a-591h, inclusive,” and made technical changes, effective July 1, 2011.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-478d. - Provider directory. Notification to enrollee of termination or withdrawal of enrollee's primary care provider.

For any contract delivered, issued for delivery, renewed, amended or continued in this state, each managed care organization shall:
(1) Provide at least annually to each enrollee a provider directory that conforms to the requirements of section 38a-477h. Such directory shall include, under a separate category or heading, participating advanced practice registered nurses; and
(2) For a managed care plan that requires the selection of a primary care provider:
(A) Allow an enrollee to designate a participating, in-network physician or a participating, in-network advanced practice registered nurse as such enrollee's primary care provider; and
(B) Provide notification in accordance with subsection (g) of section 38a-472f to each such enrollee upon the termination or withdrawal of the enrollee's primary care provider.
(P.A. 97-99, S. 5; P.A. 07-18, S. 1; P.A. 11-199, S. 1; P.A. 16-205, S. 6.)
History: P.A. 07-18 amended Subdiv. (1) to require that list of providers be given in writing or through the Internet at the option of enrollee and amended Subdiv. (2) to limit notification to enrollee in a managed care plan that requires selection of a primary care physician; P.A. 11-199 substantially revised section to require managed care organizations to include in their provider listings advanced practice registered nurses under a separate category or heading and to allow enrollees to designate a participating, in-network physician or a participating, in-network advanced practice registered nurse as such enrollee's primary care provider; P.A. 16-205 deleted former Subdiv. (1) re listing of providers, redesignated existing Subdiv. (2) as Subdiv. (1) and amended same by adding provision re provider directory and making a conforming change, and redesignated existing Subdiv. (3) re managed care plan as Subdiv. (2) and amended same by replacing “, as soon as possible” with reference to Sec. 38a-472f(g) in Subpara. (B), effective January 1, 2017.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-478e. - Medical protocols. Procedure prior to change. Physician input. Notification of change.

(a) Each managed care organization shall, prior to implementing new medical protocols or substantially or materially altering existing medical protocols, obtain input from physicians actively practicing in Connecticut and practicing in the relevant specialty areas. The managed care organization shall also seek input from physicians who are not employees of or consultants, other than to the extent a person is an employee or consultant solely for the purposes of this subsection, to the managed care organization provided the input is not unreasonably withheld. The managed care organization shall obtain the input in a manner permitting verification by the commissioner and shall document the process by which it obtained the input. For the purpose of this section, “medical protocols” shall include, but not be limited to, drug formularies or lists of covered drugs.
(b) Each managed care organization shall (1) make available, upon the request of a participating provider, its medical protocols for examination during regular business hours at the principal Connecticut headquarters of the managed care organization, and (2) if a managed care organization denies a treatment, service or procedure, the organization shall furnish, upon the request of a participating provider, a copy of the relevant medical protocol to the participating provider, along with an explanation of the denial at the time the denial is made.
(P.A. 97-99, S. 6; P.A. 00-216, S. 7, 28.)
History: P.A. 00-216 amended Subsec. (a) by making a technical change and adding provision defining “medical protocols” to include drug formularies or lists of covered drugs, effective July 1, 2000.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-478f. - Provider profile development requirements.

Each managed care organization, in developing provider profiles or otherwise measuring health care provider performance, shall: (1) Make allowances for the severity of illness or condition of the patient mix; (2) make allowances for patients with multiple illnesses or conditions; (3) make available to the commissioner documentation of how the managed care organization makes such allowances; and (4) inform enrollees and participating providers, upon request, how the managed care organization considers patient mix when profiling or evaluating providers.
(P.A. 97-99, S. 7.)
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-478h. - Contract requirements and notice for removal or departure of provider. Retaliatory action prohibited.

(a) Each contract delivered, issued for delivery, renewed, amended or continued in this state between a managed care organization and a participating provider shall conform to the requirements of section 38a-477g and shall include notice provisions for the removal or departure of such provider in accordance with subsection (g) of section 38a-472f.
(b) No managed care organization shall take or threaten to take any action against any provider in retaliation for such provider's assistance to an enrollee under the provisions of section 38a-591g.
(P.A. 97-99, S. 9; P.A. 11-58, S. 72; P.A. 16-205, S. 7.)
History: P.A. 11-58 made a technical change in Subsec. (a) and replaced references to Secs. 38a-226c(e) and 38a-478n with “section 38a-591g” in Subsec. (c), effective July 1, 2011; P.A. 16-205 amended Subsec. (a) by replacing provisions re advance written notice for withdrawal or termination of agreement with provisions re requirements of Sec. 38a-477g and notice provisions of Sec. 38a-472f(g), deleted former Subsec. (b) re exceptions and redesignated existing Subsec. (c) re managed care organization taking action against provider as Subsec. (b), effective January 1, 2017.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-478i. - Limitation on enrollee rights prohibited.

No contract delivered, issued for delivery, renewed, amended or continued in this state between a managed care organization and a participating provider shall prohibit or limit any cause of action or contract rights an enrollee otherwise has.
(P.A. 97-99, S. 10; P.A. 12-145, S. 41.)
History: P.A. 12-145 deleted “on and after October 1, 1997,”, effective June 15, 2012.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-478j. - Coinsurance and deductible payments based on negotiated discounts.

Each managed care plan that requires a deductible or percentage coinsurance payment by the insured shall calculate the insured's deductible or coinsurance payment on the lesser of the provider's or vendor's charges for the goods or services or the amount payable by the managed care organization or a subcontractor of such managed care organization for such goods or services, except as otherwise required by the laws of a foreign state when applicable to providers, vendors or patients in such foreign state.
(P.A. 97-99, S. 11; June 18 Sp. Sess. P.A. 97-8, S. 59, 88; P.A. 19-117, S. 239.)
History: June 18 Sp. Sess. P.A. 97-8 added exception re laws of a foreign state, effective July 1, 1997; P.A. 19-117 added references to deductible and added “or a subcontractor of such managed care organization”, effective January 1, 2020.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-478k. - Gag clauses prohibited.

(a) No contract delivered, issued for delivery, renewed, amended or continued in this state between a managed care organization and a participating provider shall prohibit the provider from discussing with an enrollee any treatment options and services available in or out of network, including experimental treatments.
(b) No contract delivered, issued for delivery, renewed, amended or continued in this state between a managed care organization and a participating provider shall prohibit the provider from disclosing, to an enrollee who inquires, the method the managed care organization uses to compensate the provider.
(P.A. 97-99, S. 12; P.A. 12-145, S. 42.)
History: P.A. 12-145 deleted “on and after October 1, 1997,”, effective June 15, 2012.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-478m and 38a-478n. - Internal grievance procedure; notice re procedure and final resolution; penalties; fines allocated to Office of the Healthcare Advocate. Exhaustion of internal appeal mechanisms; external appeal to commissioner; applicability to health insurers, managed care organizations and utilization review companies; fees; preliminary review; full review; public outreach program; expedited external appeal; requirements for and approval of independent review entities; filing of report.

Sections 38a-478m and 38a-478n are repealed, effective July 1, 2011.
(P.A. 97-99, S. 14, 20; June 18 Sp. Sess. P.A. 97-8, S. 60, 88; P.A. 99-284, S. 14, 35, 60; P.A. 03-278, S. 94; P.A. 04-157, S. 1; P.A. 05-29, S. 1; 05-94, S. 2, 3; 05-97, S. 1; 05-102, S. 1, 5; P.A. 06-54, S. 4; P.A. 07-75, S. 3; P.A. 08-147, S. 7; P.A. 09-49, S. 2; P.A. 11-58, S. 89.)
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-478o. - Confidentiality and antidiscrimination procedures required.

(a) Each managed care organization shall conform to all applicable state and federal antidiscrimination and confidentiality statutes, shall ensure that the confidentiality of specified enrollee patient information and records in its custody is protected, and shall have written confidentiality policies and procedures.
(b) No managed care organization shall sell, for any commercial purpose the names of its enrollees or any identifying information concerning enrollees.
(P.A. 97-99, S. 21; P.A. 98-27, S. 15.)
History: P.A. 98-27 amended Subsec. (a) to substitute “its” for “their”.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-478q. - Use of laboratories covered by plan required.

Each provider, as defined in section 38a-478, in utilizing laboratories or testing facilities for enrollees in managed care plans that provide coverage for laboratories and testing facilities, shall utilize laboratories or testing facilities covered by the enrollee's managed care plan or notify the enrollee if the provider intends to utilize a laboratory or testing facility not covered by the plan.
(P.A. 97-99, S. 25.)
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-478r. - Emergency rooms. Prudent layperson standard. Presenting symptoms or final diagnosis as basis for coverage. Mandatory coverage for medically necessary health care services for emergency medical conditions.

(a) Each provider, as defined in section 38a-478, shall code for the presenting symptoms of all emergency claims and each hospital shall record such code for such claims on locator 76 on the UB92 form or its successor.
(b) The presenting symptoms, as coded by the provider and recorded by the hospital on the UB92 form or its successor, or the final diagnosis, whichever reasonably indicates an emergency medical condition, shall be the basis for reimbursement or coverage, provided such symptoms reasonably indicated an emergency medical condition.
(c) For the purposes of this section, in accordance with the National Committee for Quality Assurance, an emergency medical condition is a condition such that a prudent layperson, acting reasonably, would have believed that emergency medical treatment is needed.
(d) The Insurance Commissioner may develop and disseminate to hospitals in this state a claims form system that will ensure that all hospitals consistently code for the presenting and diagnosis symptoms on all emergency claims.
(e) Each 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 health care services that are medically necessary, as defined in section 38a-482a or 38a-513c, as applicable, for an emergency medical condition described in subsection (c) of this section.
(P.A. 97-99, S. 26; June 18 Sp. Sess. P.A. 97-8, S. 61, 88; P.A. 11-58, S. 73; P.A. 15-118, S. 49; P.A. 19-117, S. 246.)
History: June 18 Sp. Sess. P.A. 97-8 amended Subsec. (b) to add provision re “the final diagnosis, whichever reasonably indicates an emergency medical condition,” effective July 1, 1997; P.A. 11-58 amended Subsec. (d) to delete provision re consultation with working group convened pursuant to Sec. 38a-478p, effective July 1, 2011; P.A. 15-118 made a technical change in Subsec. (c); P.A. 19-117 added Subsec. (e) re coverage for medically necessary health care services for emergency medical conditions, effective January 1, 2020.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-478s. - Nonapplicability to self-insured employee welfare benefit plans and workers' compensation plans.

(a) Nothing in sections 38a-478 to 38a-478o, inclusive, sections 38a-591a to 38a-591h, inclusive, or section 38a-591n shall be construed to apply to the arrangements of managed care organizations or health insurers offered to individuals covered under self-insured employee welfare benefit plans established pursuant to the federal Employee Retirement Income Security Act of 1974.
(b) The provisions of sections 38a-478 to 38a-478o, inclusive, sections 38a-591a to 38a-591h, inclusive, and section 38a-591n shall not apply to any plan that provides for the financing or delivery of health care services solely for the purposes of workers' compensation benefits pursuant to chapter 568.
(P.A. 97-99, S. 28, 30; June 18 Sp. Sess. P.A. 97-8, S. 64, 88; P.A. 99-284, S. 53, 60; P.A. 05-94, S. 4; P.A. 06-54, S. 5; P.A. 11-58, S. 74; P.A. 12-102, S. 9.)
History: June 18 Sp. Sess. P.A. 97-8 amended Subsec. (a) by replacing the exemption for managed care organizations with an exemption for the arrangements of managed care organizations offered to individuals covered under self-insured plans, effective July 1, 1997; P.A. 99-284 deleted obsolete reference to Sec. 38a-514a from Subsec. (b), effective January 1, 2000; P.A. 05-94 deleted references to “managed care organizations” and “employee welfare benefit plans established pursuant to the federal Employee Retirement Income Security Act of 1974”, and referenced “health plans” in Subsec. (a), effective July 1, 2005; P.A. 06-54 amended Subsec. (a) to insert “of managed care organizations or health insurers” and to substitute “self-insured employee welfare benefit plans established pursuant to the federal Employee Retirement Income Security Act of 1974” for “self-insured health plans”, effective May 8, 2006; P.A. 11-58 added references to Secs. 38a-591a to 38a-591h, effective July 1, 2011; P.A. 12-102 added references to Sec. 38a-591n.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-478t. - Commissioner of Public Health to receive data.

The Commissioner of Public Health may request and shall receive any data, report or information filed with the Insurance Commissioner pursuant to the provisions of sections 38a-478 to 38a-478u, inclusive, 38a-479aa, 38a-591j, 38a-591k and 38a-993.
(P.A. 97-99, S. 31; P.A. 99-284, S. 54, 60; June Sp. Sess. P.A. 01-4, S. 25; P.A. 11-58, S. 75.)
History: P.A. 99-284 deleted obsolete reference to Sec. 38a-514a, effective January 1, 2000; June Sp. Sess. P.A. 01-4 replaced reference to Sec. 19a-647 with reference to Sec. 38a-479aa; P.A. 11-58 replaced reference to Secs. 38a-226 to 38a-226d with reference to Secs. 38a-591j and 38a-591k, effective July 1, 2011.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-478u. - Regulations.

The Insurance Commissioner may adopt regulations in accordance with the provisions of chapter 54 to implement the provisions of sections 38a-478 to 38a-478u, inclusive, 38a-479aa and 38a-993.
(P.A. 97-99, S. 29; P.A. 99-284, S. 55, 60; June Sp. Sess. P.A. 01-4, S. 26; P.A. 03-199, S. 5; P.A. 11-58, S. 76.)
History: P.A. 99-284 deleted obsolete reference to Sec. 38a-514a, effective January 1, 2000; June Sp. Sess. P.A. 01-4 replaced reference to Sec. 19a-647 with reference to Sec. 38a-479aa; P.A. 03-199 substituted “may adopt” for “shall adopt” re regulations; P.A. 11-58 deleted reference to Secs. 38a-226 to 38a-226d, effective July 1, 2011.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-478v. - Applicability of Unfair and Prohibited Insurance Practices Act. Examination by Insurance Commissioner. Regulations.

(a) Each managed care organization, as defined in section 38a-478, shall be subject to the provisions of sections 38a-815 to 38a-819, inclusive.
(b) The Insurance Commissioner may examine the affairs of any managed care organization licensed to do business in this state in order to determine whether such managed care organization has been or is engaged in any unfair method of competition or in any unfair or deceptive act or practice prohibited by section 38a-816. The commissioner may adopt regulations, in accordance with the provisions of chapter 54, to implement the provisions of this section.
(P.A. 99-284, S. 31.)
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-478w. - Managed care organization's calculation of enrollee liability for covered benefits. Credit required for third-party discounts and payments.

For any contract delivered, issued for delivery, renewed, amended or continued in this state on or after January 1, 2022, each managed care organization shall, when calculating an enrollee's liability for a coinsurance, copayment, deductible or other out-of-pocket expense for a covered benefit, give credit for any discount provided or payment made by a third party for the amount of, or any portion of the amount of, the coinsurance, copayment, deductible or other out-of-pocket expense for the covered benefit.
(P.A. 21-14, S. 4.)
History: P.A. 21-14 effective January 1, 2022.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-479a. - Physicians and managed care organizations to discuss issues relative to contracting between such parties.

The chairpersons and ranking members of the joint standing committee of the General Assembly having cognizance of matters relating to insurance shall convene, at least two times each year, a group of physicians and managed care organizations, to discuss issues relative to contracting between physicians and managed care organizations, including issues relative to any national settlement agreements, to the extent permitted under such settlement agreements.
(P.A. 06-178, S. 2.)
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-479cc. - Duties of a preferred provider network when providing services pursuant to a contract with a managed care organization.

(a) Whenever a preferred provider network is providing services pursuant to a contract with a managed care organization, the preferred provider network may not establish any terms, conditions or requirements for access, diagnosis or treatment that are different from the terms, conditions or requirements for access, diagnosis or treatment in the managed care organization's plan, except that no preferred provider network shall be required to provide an enrollee access to a provider who does not participate in the preferred provider network unless the preferred provider network is required to provide such access under its contract with the managed care organization.
(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.
(P.A. 03-169, S. 3; P.A. 06-196, S. 164.)
History: P.A. 06-196 made a technical change in Subsec. (a), effective June 7, 2006.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-479dd. - Preferred provider network examination of outstanding amounts. Notice. Commissioner's duties.

Each preferred provider network shall examine its outstanding amounts in each quarter and if the preferred provider network determines that the outstanding amounts in a quarter will exceed ninety-five per cent of the security posted pursuant to subsection (i) of section 38a-479aa, the preferred provider network shall mail a notice to each of its participating providers concerning the status of incurred claims and shall send notice to each managed care organization with which it contracts and the Insurance Commissioner on such form as the commissioner prescribes. The commissioner shall meet with the applicable managed care organization and preferred provider network to ensure continued services to enrollees and payment to providers.
(P.A. 03-169, S. 4.)
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-479ff. - Adverse action or threat of adverse action against complainant prohibited. Exception. Civil actions by aggrieved persons.

No health insurer, health care center, utilization review company, as defined in section 38a-591a, or preferred provider network, as defined in section 38a-479aa, shall take or threaten to take any adverse personnel or coverage-related action against any enrollee, provider or employee in retaliation for such enrollee, provider or employee (1) filing a complaint with the Insurance Commissioner or the Office of the Healthcare Advocate, or (2) disclosing information to the Insurance Commissioner concerning any violation of this part or sections 38a-815 to 38a-819, inclusive, unless such disclosure violates the provisions of chapter 705 or the privacy provisions of the federal Health Insurance Portability and Accountability Act of 1996, P.L. 104-191, as amended from time to time, or regulations adopted thereunder. Any enrollee, provider or employee who is aggrieved by a violation of this section may bring a civil action in the Superior Court to recover damages and attorneys' fees and costs.
(P.A. 03-169, S. 6; P. A. 05-102, S. 7; P.A. 11-58, S. 80.)
History: P.A. 05-102 renamed the Office of Managed Care Ombudsman the Office of the Healthcare Advocate; P.A. 11-58 replaced reference to Sec. 38a-226 with “section 38a-591a”, deleted reference to Secs. 38a-226 to 38a-226d and made a technical change, effective July 1, 2011.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-479aaa. - Pharmacy benefits managers. Definitions.

As used in this section and sections 38a-479bbb to 38a-479iii, inclusive:
(1) “Commissioner” means the Insurance Commissioner;
(2) “Department” means the Insurance Department;
(3) “Drug” has the same meaning as provided in section 21a-92;
(4) “Person” has the same meaning as provided in section 38a-1;
(5) “Pharmacist services” includes (A) drug therapy and other patient care services provided by a licensed pharmacist intended to achieve outcomes related to the cure or prevention of a disease, elimination or reduction of a patient's symptoms, and (B) education or intervention by a licensed pharmacist intended to arrest or slow a disease process;
(6) “Pharmacist” means an individual licensed to practice pharmacy under section 20-590, 20-591, 20-592 or 20-593, and who is thereby recognized as a health care provider by the state of Connecticut;
(7) “Pharmacy” means a place of business where drugs may be sold at retail and for which a pharmacy license has been issued to an applicant pursuant to section 20-594; and
(8) “Pharmacy benefits manager” or “manager” means any person that administers the prescription drug, prescription device, pharmacist services or prescription drug and device and pharmacist services portion of a health benefit plan on behalf of plan sponsors such as self-insured employers, insurance companies, labor unions and health care centers.
(P.A. 07-200, S. 1; P.A. 14-193, S. 2; P.A. 18-68, S. 9.)
History: P.A. 07-200 effective January 1, 2008; P.A. 14-193 added reference to Sec. 38a-479iii in introductory language; P.A. 18-68 made technical changes in Subdivs. (3) and (4).
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-479bbb. - Registration of pharmacy benefits managers required. Application for registration. Fee. Surety bond. Exemption from registration.

(a) Except as provided in subsection (d) of this section, no person shall act as a pharmacy benefits manager in this state without first obtaining a certificate of registration from the commissioner.
(b) Any person seeking a certificate of registration shall apply to the commissioner, in writing, on a form provided by the commissioner. The application form shall state (1) the name, address, official position and professional qualifications of each individual responsible for the conduct of the affairs of the pharmacy benefits manager, including all members of the board of directors, board of trustees, executive committee, other governing board or committee, the principal officers in the case of a corporation, the partners or members in the case of a partnership or association and any other person who exercises control or influence over the affairs of the pharmacy benefits manager, and (2) the name and address of the applicant's agent for service of process in this state.
(c) Each application for a certificate of registration shall be accompanied by (1) a nonrefundable fee of fifty dollars, and (2) evidence of a surety bond in an amount equivalent to ten per cent of one month of claims in this state over a twelve-month average, except that such bond shall not be less than twenty-five thousand dollars or more than one million dollars.
(d) Any pharmacy benefits manager operating as a line of business or affiliate of a health insurer, health care center, hospital service corporation, medical service corporation or fraternal benefit society licensed in this state or any affiliate of such health insurer, health care center, hospital service corporation, medical service corporation or fraternal benefit society shall not be required to obtain a certificate of registration. Such health insurer, health care center, hospital service corporation, medical service corporation or fraternal benefit society shall notify the commissioner annually, in writing, on a form provided by the commissioner, that it is affiliated with or operating a business as a pharmacy benefits manager.
(P.A. 07-200, S. 2; P.A. 14-193, S. 3; 14-235, S. 54.)
History: P.A. 07-200 effective January 1, 2008; P.A. 14-193 deleted former Subsec. (e) re 2008 registration requirement for pharmacy benefits manager; P.A. 14-235 made identical change as P.A. 14-193.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-479ccc. - Certificate of registration; when issued or refused. Suspension, revocation or refusal to issue or renew registration; grounds.

(a) Upon receipt of a completed application, evidence of a surety bond and fee, the commissioner shall: (1) Issue and deliver to the applicant a certificate of registration; or (2) refuse to issue the certificate.
(b) The commissioner may suspend, revoke or refuse to issue or renew any certificate of registration for: (1) Conduct of a character likely to mislead, deceive or defraud the public or the commissioner; (2) unfair or deceptive business practices; or (3) nonpayment of the renewal fee.
(c) The commissioner shall not suspend or revoke any certificate of registration except upon notice and hearing in accordance with chapter 54.
(P.A. 07-200, S. 3.)
History: P.A. 07-200 effective January 1, 2008.
2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-479ddd. - Hearing on denial of certificate. Subsequent application.

(a) Upon refusal to issue or renew a certificate, the commissioner shall notify the applicant of the denial and of the applicant's right to request a hearing within ten days from the date of receipt of the notice of denial.
(b) If the applicant requests a hearing within such ten days, the commissioner shall give notice of the grounds for the commissioner's refusal and shall conduct a hearing concerning such refusal in accordance with the provisions of chapter 54 concerning contested cases.
(c) If the commissioner's denial of a certificate is sustained after such hearing, an applicant may make a new application not less than one year after the date on which such denial was sustained.
(P.A. 07-200, S. 4.)
History: P.A. 07-200 effective January 1, 2008.