Connecticut Administrative Code › Title 38a - Insurance Department › 546 - Group Coverage Discontinuance and Replacement › Section 38a-546-5 - Group extension of benefits, continuation of benefits, conversion, and pre-existing conditions

Current through July 10, 2024
(a)
Extension
			 of benefits.
In accordance with section
			 38a-546
			 of the Connecticut General Statutes, every group insurance policy shall provide
			 a reasonable provision for extension of benefits in the event of total
			 disability at the date of discontinuance of the group insurance policy, as
			 follows:
(1) In the case of a group life plan
			 that contains a disability benefit extension of any type (e.g., premium waiver
			 extension, extended death benefit in event of total disability, or payment of
			 income for a specified period during total disability), the discontinuance of
			 the group insurance policy shall not operate to terminate such
			 extension.
(2) In the case of a
			 group disability income protection policy or group hospital confinement
			 indemnity policy, discontinuance of the policy during a disability shall have
			 no effect on benefits payable for that disability or confinement.
(3) In the case of a group health insurance
			 plan, the extension of benefits provision shall provide coverage set forth in
			 subparagraphs (A), (B), and (C) of this subdivision.
(A) No succeeding carrier. When there is no
			 succeeding group health insurance plan sponsored by the employer and insured by
			 another carrier, for covered individuals who were confined to a health care
			 facility or totally disabled, on the date the policy is discontinued, the group
			 health insurance plan shall provide coverage for the confinement including
			 professional services and supplies rendered during the confinement in the
			 health care facility and for all services related to the disabling condition,
			 as applicable, without premium payment, according to the terms of its plan.
(i) Length of extension. The extension will
			 apply until the date the covered individual is not confined to a health care
			 facility, or for those not confined to a health care facility - not totally
			 disabled, or the date that is twelve calendar months following the date the
			 policy was discontinued, whichever is earlier.
(ii) Submission of claim. Extension of
			 benefits will be available provided that evidence of the facility confinement,
			 if any, and any disabling condition is submitted within one year of the
			 termination of the plan and claims for coverage are submitted in accordance
			 with the plan terms.
(B)
			 Succeeding carrier for person confined in a health care facility. When the
			 group health insurance plan is replaced by a succeeding group health insurance
			 plan sponsored by the employer and insured by another carrier, for covered
			 individuals who were confined to a health care facility on the date the policy
			 is discontinued, the prior group health plan shall provide coverage for the
			 confinement including professional services and supplies rendered during the
			 confinement in the health care facility, without premium payment.
(i) Length of extension. The extension will
			 apply until the date the covered individual is not confined to a health care
			 facility, or the date that is twelve calendar months following the date the
			 policy was discontinued, whichever is earlier.
(ii) Submission of claim. Extension of
			 benefits will be available provided that evidence of facility confinement and
			 any disabling condition is submitted within one year of the termination of the
			 plan and claims for coverage are submitted in accordance with the plan
			 terms.
(iii) Transition of care.
			 The succeeding carrier shall be responsible for all other coverage for the
			 individual, including transition of care benefits that provide the individual
			 with a reasonable opportunity to use their current health care provider(s) for
			 a period of time that is clinically appropriate for the treatment of the
			 condition related to the confinement. During the transitional period, benefits
			 under the succeeding carrier's plan for treatment of the condition related to
			 the confinement will not be reduced because of lack of participation in the
			 succeeding carrier's network or lack of certification by the succeeding carrier
			 for services pre-certified by the prior carrier. Nothing herein shall be
			 construed as authorizing or requiring medical necessity certification
			 procedures between the managed care organization and the provider that are not
			 set forth in the contract between the managed care organization and the
			 provider.
(C) Succeeding
			 carrier for a totally disabled person not confined in a health care facility.
			 When the group health insurance plan is replaced by a succeeding group health
			 insurance plan sponsored by the employer and insured by another carrier, for
			 covered individuals who are totally disabled but not confined to a health care
			 facility on the date the policy is discontinued, the succeeding group health
			 plan shall provide coverage in accordance with the plan terms.
(i) Transition of care. The succeeding
			 carrier shall be responsible for all coverage for the totally disabled
			 individual, including transition of care benefits that provide the individual
			 with a reasonable opportunity to use their current health care provider(s) for
			 a period of time that is clinically appropriate for the treatment of the
			 disabling condition. During the transitional period, benefits under the
			 succeeding carrier's plan for treatment of the disabling condition will not be
			 reduced because of lack of participation in the succeeding carrier's network or
			 lack of certification by the succeeding carrier for services pre-certified by
			 the prior carrier. Nothing herein shall be construed as authorizing or
			 requiring medical necessity certification procedures between the managed care
			 organization and the provider that are not set forth in the contract between
			 the managed care organization and the provider.