Connecticut Administrative Code › Title 38a - Insurance Department › 513 - Group Specified Disease Health Insurance Minimum Standards › Section 38a-513-1 - Definitions

Current through July 10, 2024
As used in sections 38a-513-1 to 38a-513-13, inclusive, of the
				Regulations of Connecticut State Agencies, unless otherwise provided:
(1) "Activities of daily living" means
			 activities such as bathing, dressing, eating, toileting, and
			 transferring.
(2) "Commissioner"
			 means the Insurance Commissioner of the State of Connecticut.
(3) "Department" means the Connecticut
			 Insurance Department.
(4)
			 "Excessive rate" means the rate is unreasonably high for the insurance
			 provided.
(5) "Experience period"
			 means the most recent twelve (12) month period from which the insurer
			 accumulates the data to support a rate filing.
(6) "Form" means a policy or certificate of
			 insurance against loss or expense from sickness, or from bodily injury or death
			 by accident, or application, rider or endorsement used in connection
			 therewith.
(7) "Formulary" means a
			 list of prescription drugs that are covered by a specific health insurance
			 plan.
(8) "Group specified disease
			 policy" means a group health insurance plan or certificate delivered or issued
			 for delivery in this state which pays benefits for the diagnosis or treatment
			 of one or more specifically named diseases, conditions or syndromes in
			 accordance with section 38a-513-4(g)(13) of the Regulations of Connecticut
			 State Agencies.
(9) "Health
			 insurance plan" has the same meaning as provided in Section 38a-564 of the
			 Connecticut General Statutes.
(10)
			 "Inadequate rate" means a rate that is unreasonably low for the insurance
			 provided, and continued use of it would endanger solvency of the
			 insurer.
(11) ''Insurer'' means a
			 health care center, as defined in Section 38a-175 of the Connecticut General
			 Statutes, or an insurance company licensed by the Commissioner to write
			 accident and health insurance.
(12)
			 "Loss ratio" has the same meaning as provided in Section 38a-481(a) of the
			 Connecticut General Statutes.
(13)
			 "One period of confinement" means consecutive days of in-hospital service
			 received as an inpatient, or successive confinements when discharge from and
			 readmission to the hospital occurs within a period of not more than ninety (90)
			 days or three times the maximum number of days of in-hospital coverage provided
			 by the policy to a maximum of one hundred and eighty (180) days.
(14) "Pharmaceutical and therapeutics
			 committee" or "P&T committee" means a group of members that may include
			 physicians, pharmacists, administrators, quality improvement managers, other
			 health care professionals and staff appointed by an insurer to establish
			 policies regarding the use of drugs, therapies and drug-related products,
			 identifying those that are most medically appropriate and cost
			 effective.
(15) "PPACA" means
			 Patient Protection and Affordable Care Act,
			 P.L.
			 111-148, as amended from time to time, and
			 regulations adopted thereunder.
(16) "Prescription drug tier" means a subset
			 of the drugs covered in a formulary that are covered and subject to a specified
			 level of cost share.
(17) "SERFF"
			 means the National Association of Insurance Commissioners' System for
			 Electronic Rate and Form Filing.
(18) "Small employer" has the same meaning as
			 provided in Section 38a-564 of the Connecticut General Statutes.
(19) "Specialty drug" means a unique
			 prescription drug that may require special handling, close monitoring or may
			 only be available from limited pharmacies.
(20) "Unfairly discriminatory" means rating
			 practices that reflect differences based on age, disability, race, ethnicity,
			 gender, sexual orientation or health status that are not actuarially justified
			 or are otherwise prohibited by law
(21) "Utilization data" means the number of
			 services used by a fixed number of covered persons, as defined in Section
			 38a-591a of the Connecticut General Statutes, over a fixed length of
			 time.