Sec. 38a-477cc. Contracts for pharmacy services with health carriers or pharmacy benefits managers.
Sec. 38a-479kkk. Duty of good faith and fair dealing.
Sec. 38a-479ttt. Annual report by commissioner to the General Assembly re prescription drug rebates.
Sec. 38a-479uuu. Annual report by health carriers re pricing and profit generated.
Sec. 38a-492w. Medically necessary wheelchair repairs, replacements. Coverage requirements.
Sec. 38a-492y. Mandatory coverage for biomarker testing.
Sec. 38a-499b. Reimbursement for general anesthesia re time limit restrictions.
Sec. 38a-510. Prescription drug coverage. Mail order pharmacies. Step therapy use.
Sec. 38a-518w. Medically necessary wheelchair repairs, replacements. Coverage requirements.
Sec. 38a-518y. Mandatory coverage for biomarker testing.
Sec. 38a-526b. Reimbursement for general anesthesia re time limit restrictions.
Sec. 38a-544. Prescription drug coverage. Mail order pharmacies. Step therapy use.
Sec. 38a-477d. Information to be made available to consumers. Explanations of benefits. Disclosures by health carriers. Specifications by consumers. Restrictions. Electronic delivery of policy documents and communications. (a) Each insurer, health care center, hospital service corporation, medical service corporation, fraternal benefit society or other entity that delivers, issues for delivery, renews, amends or continues a health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 in this state, shall:
(1) Make available to consumers, in an easily readable, accessible and understandable format:
(A) The following information for each such policy:
(i) Any coverage exclusions;
(ii) Any restrictions on the use or quantity of a covered benefit, including on prescription drugs or drugs administered in a physician's office or a clinic;
(iii) A specific description of how prescription drugs are included or excluded from any applicable deductible, including a description of other out-of-pocket expenses that apply to such drugs;
(iv) The specific dollar amount of any copayment and the percentage of any coinsurance imposed on each covered benefit, including each covered prescription drug; and
(v) Information regarding any process available to consumers, and all documents necessary, to seek coverage of a noncovered outpatient prescription drug; and
(B) With respect to explanations of benefits issued pursuant to subsections (d) to (i), inclusive, of this section, a statement disclosing that each consumer who is a covered individual and legally capable of consenting to the provision of covered benefits under such policy may specify that such insurer, center, corporation, society or entity, and each third-party administrator, as defined in section 38a-720, providing services to such insurer, center, corporation, society or entity, shall:
(i) Not issue explanations of benefits concerning covered benefits provided to such consumer; or
(ii) (I) Issue explanations of benefits concerning covered benefits provided to such consumer solely to such consumer; and
(II) Use a method specified by such consumer to issue such explanations of benefits solely to such consumer, and provide sufficient space in the statement for such consumer to specify a mailing address or an electronic mail address for such insurer, center, corporation, society, entity or third-party administrator to use to contact such consumer concerning covered benefits provided to such consumer.
(2) Make available to consumers a way to determine accurately:
(A) Whether a specific prescription drug is available under such policy's drug formulary;
(B) The coinsurance, copayment, deductible or other out-of-pocket expense applicable to such drug;
(C) Whether such drug is covered when dispensed by a physician or a clinic;
(D) Whether such drug requires prior authorization or the use of step therapy;
(E) Whether specific types of health care specialists are in-network; and
(F) Whether a specific health care provider or hospital is in-network.
(b) (1) Each insurer, health care center, hospital service corporation, medical service corporation, fraternal benefit society or other entity shall make the information and statement required under subsection (a) of this section available to consumers at the time of enrollment and shall post such information and statement on its Internet web site.
(2) The Connecticut Health Insurance Exchange, established pursuant to section 38a-1081, shall post links on its Internet web site to such information and statement for each qualified health plan that is offered or sold through the exchange.
(c) The Insurance Commissioner shall post links on the Insurance Department's Internet web site to any on-line tools or calculators to help consumers compare and evaluate health insurance policies and plans.
(d) Except as provided in subsection (g) of this section, each insurer, health care center, hospital service corporation, medical service corporation, fraternal benefit society or other entity that delivers, issues for delivery, renews, amends or continues a health insurance policy described in subsection (a) of this section, and each third-party administrator, as defined in section 38a-720, providing services to such an insurer, center, corporation, society or entity, shall:
(1) Issue explanations of benefits to consumers who are covered individuals under the policy; and
(2) Permit each consumer who is a covered individual under the policy and legally capable of consenting to the provision of covered benefits to specify, in writing, that such insurer, center, corporation, society, entity or third-party administrator issue explanations of benefits concerning covered benefits provided to such consumer solely to such consumer, and specify, in writing, which of the following methods such insurer, center, corporation, society, entity or third-party administrator shall use to issue such explanations of benefits solely to such consumer:
(A) Mailing such explanations of benefits to such consumer's mailing address or another mailing address specified by such consumer; or
(B) Making such explanations of benefits available to such consumer by electronic means and notifying such consumer by electronic means, including, but not limited to, electronic mail, when such insurer, center, corporation, society, entity or third-party administrator makes each such explanation of benefits available to such consumer by electronic means, provided making such explanations of benefits available to such consumer by electronic means and notifying such consumer by electronic means complies with all applicable federal and state laws and regulations concerning data security, including, but not limited to, 45 CFR Part 160, as amended from time to time, and 45 CFR Part 164, Subparts A and C, as amended from time to time.
(e) Each method specified by a consumer, in writing, pursuant to subdivision (2) of subsection (d) of this section shall be valid until the consumer submits a written specification to the insurer, center, corporation, society, entity or third-party administrator for a different method. Such insurer, center, corporation, society, entity or third-party administrator shall comply with a written specification under this subsection or subdivision (2) of subsection (d) of this section, as applicable, not later than three business days after such insurer, center, corporation, society, entity or third-party administrator receives such specification.
(f) Each insurer, center, corporation, society, entity or third-party administrator that receives a written specification from a consumer pursuant to subdivision (2) of subsection (d) of this section or subsection (e) of this section, as applicable, shall provide the consumer who made such specification with written confirmation that such insurer, center, corporation, society, entity or third-party administrator received such specification, and advise such consumer, in writing, regarding the status of such specification if such consumer contacts such insurer, center, corporation, society, entity or third-party administrator, in writing, regarding such specification.
(g) Each consumer who is a covered individual under a policy described in subsection (a) of this section and is legally capable of consenting to the provision of covered benefits may specify, in writing, that the insurer, center, corporation, society or entity that delivered, issued for delivery, renewed, amended or continued the policy, or a third-party administrator providing services to such insurer, center, corporation, society or entity, not issue explanations of benefits pursuant to subsections (d) to (f), inclusive, of this section if such explanations of benefits concern covered benefits that were provided to such consumer. Such insurer, center, corporation, society, entity or third-party administrator shall not require such consumer to provide any explanation regarding the basis for such consumer's specification, unless such explanation is required by applicable law or pursuant to an order issued by a court of competent jurisdiction.
(h) Each insurer, center, corporation, society or entity that delivers, issues for delivery, renews, amends or continues a policy described in subsection (a) of this section, and each third-party administrator providing services to such insurer, center, corporation, society or entity, shall disclose to each consumer who is a covered individual under the policy such consumer's ability to submit specifications pursuant to subsections (d) to (g), inclusive, of this section. Such disclosure shall be in plain language and displayed or printed, as applicable, clearly and conspicuously in all evidence of coverage documents, privacy communications, explanations of benefits and Internet web sites that are maintained by such insurer, center, corporation, society, entity or third-party administrator and accessible to consumers in this state.
(i) No insurer, center, corporation, society or entity that is subject to subsections (d) to (h), inclusive, of this section shall require a consumer or policyholder to waive any right to limit disclosure under subsections (d) to (h), inclusive, of this section as a precondition to delivering, issuing for delivery, renewing, amending or continuing a policy described in subsection (a) of this section to the consumer or policyholder. Nothing in this subsection or subsections (d) to (h), inclusive, of this section shall be construed to limit a consumer's or policyholder's ability to request review of an adverse determination.
(j) Notwithstanding the provisions with respect to explanation of benefits set forth in subsections (d) to (h), inclusive, of this section, each insurer, health care center, hospital service corporation, medical service corporation, fraternal benefit society or other entity that delivers, issues for delivery, renews, amends or continues a health insurance policy providing coverage shall permit each consumer who is a covered individual under the policy and legally capable of consenting to the provision of covered benefits under such policy to specify, in writing, that such insurer, health care center, hospital service corporation, medical service corporation, fraternal benefit society or other entity make all documents pertaining to coverage available by electronic means, provided making such documents available to such consumer by electronic means complies with all applicable federal and state laws and regulations concerning data security, including, but not limited to, 45 CFR Part 160, as amended from time to time, and 45 CFR Part 164, Subparts A and C, as amended from time to time.
(k) (1) Notwithstanding the provisions with respect to explanation of benefits set forth in subsections (d) to (h), inclusive, of this section, each insurer, health care center, hospital service corporation, medical service corporation, fraternal benefit society or other entity that delivers, issues for delivery, renews, amends or continues a health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 in this state on or after January 1, 2026, may allow a plan sponsor of a health insurance policy, on behalf of consumers who are covered individuals under such policy, to consent to the delivery of all communications pertaining to such policy by electronic means, provided each covered individual under such policy (A) is provided, at the time of enrollment or within a reasonable amount of time prior to such delivery of communications pertaining to such policy by electronic means, (i) notification of such delivery of all communications pertaining to such policy by electronic means, and (ii) an opportunity to choose delivery of such communications pertaining to such policy by mail in lieu of delivery by electronic means, and (B) may, at any time, submit a request to such insurer, center, corporation, society or other entity to opt out of such delivery of communications pertaining to such policy by electronic means.
(2) The Insurance Commissioner may adopt regulations, in accordance with the provisions of chapter 54, to implement the provisions of this subsection.
(P.A. 15-146, S. 7; P.A. 17-15, S. 43, 44; P.A. 18-41, S. 11; P.A. 21-22, S. 1; P.A. 23-171, S. 21; P.A. 25-87, S. 2.)
History: P.A. 15-146 effective January 1, 2016; P.A. 17-15 made technical changes in Subsecs. (a)(2)(D) and (c); P.A. 18-41 amended Subsec. (a)(1) by adding “, accessible” and Subpara. (E) re coverage of noncovered outpatient prescription drugs, effective January 1, 2020; P.A. 21-22 amended Subsec. (a) by dividing existing Subdiv. (1) into Subdivs. (1) and (1)(A), redesignating existing Subdivs. (1)(A) to (1)(E) as Subdivs. (1)(A)(i) to (1)(A)(v), adding new Subdiv. (1)(B) re statement disclosing information re explanations of benefits and making technical and conforming changes, amended Subsec. (b) by adding references to statement and added Subsecs. (d) to (i) re explanations of benefits, disclosures and prohibitions, effective January 1, 2023; P.A. 23-171 added Subsec. (j) re covered individuals may request all documents pertaining to coverage be made available by electronic means; P.A. 25-87 added Subsec. (k)(1) to allow plan sponsors to consent to electronic delivery of policy communications on behalf of covered individuals and require notice and opportunity to opt out of electronic delivery of policy communications, and added Subsec. (k)(2) to authorize commissioner to adopt regulations to implement the provisions of this subsection, effective January 1, 2026.
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Sec. 38a-477cc. Contracts for pharmacy services with health carriers or pharmacy benefits managers. (a) No contract for pharmacy services entered into in the state between a health carrier, as defined in section 38a-591a, or pharmacy benefits manager, as defined in section 38a-479aaa, and a pharmacy or pharmacist shall:
(1) On and after January 1, 2018, contain a provision prohibiting or penalizing, including through increased utilization review, reduced payments or other financial disincentives, a pharmacist's disclosure to an individual purchasing prescription medication of information regarding:
(A) The cost of the prescription medication to the individual; or
(B) The availability of any therapeutically equivalent alternative medications or alternative methods of purchasing the prescription medication, including, but not limited to, paying a cash price, that are less expensive than the cost of the prescription medication to the individual; and
(2) On and after January 1, 2020, contain a provision permitting the health carrier or pharmacy benefits manager to recoup, directly or indirectly, from a pharmacy or pharmacist any portion of a claim that such health carrier or pharmacy benefits manager has paid to the pharmacy or pharmacist, unless such recoupment is permitted under section 38a-479iii or required by applicable law.
(b) (1) On and after January 1, 2018, no health carrier or pharmacy benefits manager shall require an individual to make a payment at the point of sale for a covered prescription medication in an amount greater than the lesser of:
(A) The applicable copayment for such prescription medication;
(B) The allowable claim amount for the prescription medication; or
(C) The amount an individual would pay for the prescription medication if the individual purchased the prescription medication without using a health benefit plan, as defined in section 38a-591a, or any other source of prescription medication benefits or discounts.
(2) For the purposes of this subsection, “allowable claim amount” means the amount the health carrier or pharmacy benefits manager has agreed to pay the pharmacy for the prescription medication.
(c) On and after January 1, 2026, a pharmacy benefits manager shall offer a health plan the option of being charged the same price for a prescription drug that such pharmacy benefits manager pays a pharmacy for such prescription drug.
(d) Any provision of a contract that violates the provisions of this section shall be void and unenforceable. Any general business practice that violates the provisions of this section shall constitute an unfair trade practice pursuant to chapter 735a. The invalidity or unenforceability of any contract provision under this subsection shall not affect any other provision of the contract.
(e) The Insurance Commissioner may:
(1) Enforce the provisions of this section pursuant to chapter 697; and
(2) Upon request, audit a contract for pharmacy services for compliance with the provisions of this section.
(P.A. 17-241, S. 1; P.A. 19-199, S. 1; P.A. 25-167, S. 2.)
History: P.A. 19-199 amended Subsec. (a) by deleting reference to January 1, 2018, designating existing provisions re contract for pharmacy services as new Subdiv. (1) and amending same by adding reference to January 1, 2018, redesignating existing Subdiv. (1) as Subpara. (A) and redesignating existing Subdiv. (2) as Subpara. (B), and adding new Subdiv. (2) re contract for pharmacy services on and after January 1, 2020, amended Subsec. (b) by designating existing provisions re payment at point of sale for prescription medication as new Subdiv. (1), redesignating existing Subdiv. (1) as Subpara. (A), redesignating existing Subdivs. (2) and (3) as Subparas. (B) and (C), and designating existing provision defining “allowable claim amount” as Subdiv. (2), and made technical and conforming changes; P.A. 25-167 added new Subsec. (c) re health plans offered option to be charged same price for a prescription drug that pharmacy benefits manager pays a pharmacy for such prescription drug, and redesignated existing Subsecs. (c) and (d) as Subsecs. (d) and (e), effective January 1, 2026.
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Sec. 38a-477ee. Mental health and substance use disorder benefits. Nonquantitative treatment limitations. Reports. Public hearings. Regulations. (a) For the purposes of this section:
(1) “Health carrier” has the same meaning as provided in section 38a-1080;
(2) “Mental health and substance use disorder benefits” means all benefits for the treatment of a mental health condition or a substance use disorder that (A) falls under one or more of the diagnostic categories listed in the chapter concerning mental disorders in the most recent edition of the International Classification of Diseases, or (B) is a mental disorder, as that term is defined in the most recent edition of the American Psychiatric Association's “Diagnostic and Statistical Manual of Mental Disorders”; and
(3) “Nonquantitative treatment limitation” means a limitation that cannot be expressed numerically but otherwise limits the scope or duration of a covered benefit.
(b) Not later than March 1, 2021, and annually thereafter, each health carrier shall submit a report to the Insurance Commissioner, in a form and manner prescribed by the commissioner, containing the following information for the calendar year immediately preceding:
(1) A description of the processes that such health carrier used to develop and select criteria to assess the medical necessity of (A) mental health and substance use disorder benefits, and (B) medical and surgical benefits;
(2) A description of all nonquantitative treatment limitations that such health carrier applied to (A) mental health and substance use disorder benefits, and (B) medical and surgical benefits; and
(3) The results of an analysis concerning the processes, strategies, evidentiary standards and other factors that such health carrier used in developing and applying the criteria described in subdivision (1) of this subsection and each nonquantitative treatment limitation described in subdivision (2) of this subsection, provided the commissioner shall not disclose such results in a manner that is likely to compromise the financial, competitive or proprietary nature of such results. The results of such analysis shall, at a minimum:
(A) Disclose each factor that such health carrier considered, regardless of whether such health carrier rejected such factor, in (i) designing each nonquantitative treatment limitation described in subdivision (2) of this subsection, and (ii) determining whether to apply such nonquantitative treatment limitation;
(B) Disclose any and all evidentiary standards, which standards may be qualitative or quantitative in nature, applied under a factor described in subparagraph (A) of this subdivision, and, if no evidentiary standard is applied under such a factor, a clear description of such factor;
(C) Provide the comparative analyses, including the results of such analyses, performed to determine that the processes and strategies used to design each nonquantitative treatment limitation, as written, and the processes and strategies used to apply such nonquantitative treatment limitation, as written, to mental health and substance use disorder benefits are comparable to, and applied no more stringently than, the processes and strategies used to design each nonquantitative treatment limitation, as written, and the processes and strategies used to apply such nonquantitative treatment limitation, as written, to medical and surgical benefits;
(D) Provide the comparative analyses, including the results of such analyses, performed to determine that the processes and strategies used to apply each nonquantitative treatment limitation, in operation, to mental health and substance use disorder benefits are comparable to, and applied no more stringently than, the processes and strategies used to apply each nonquantitative treatment limitation, in operation, to medical and surgical benefits; and
(E) Disclose information that, in the opinion of the Insurance Commissioner, is sufficient to demonstrate that such health carrier, consistent with the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, P.L. 110-343, as amended from time to time, and regulations adopted thereunder, (i) applied each nonquantitative treatment limitation described in subdivision (2) of this subsection comparably, and not more stringently, to (I) mental health and substance use disorder benefits, and (II) medical and surgical benefits, and (ii) complied with (I) sections 38a-488c and 38a-514c, (II) sections 38a-488a and 38a-514, (III) sections 38a-510 and 38a-544, and (IV) the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, P.L. 110-343, as amended from time to time, and regulations adopted thereunder.
(c) Not later than April 15, 2021, and annually thereafter, the Insurance Commissioner shall submit each report that the commissioner received pursuant to subsection (b) of this section for the calendar year immediately preceding to:
(1) The joint standing committee of the General Assembly having cognizance of matters relating to insurance, in accordance with section 11-4a; and
(2) The Attorney General, Healthcare Advocate and Commissioner of Health Strategy.
(d) Not later than May 15, 2021, and annually thereafter, the joint standing committee of the General Assembly having cognizance of matters relating to insurance may hold a public hearing concerning the reports that such committee received pursuant to subsection (c) of this section for the calendar year immediately preceding. The Insurance Commissioner, or the commissioner's designee, shall attend the public hearing and inform the committee whether, in the commissioner's opinion, each health carrier, for the calendar year immediately preceding, (1) submitted a report pursuant to subsection (b) of this section that satisfies the requirements established in said subsection, and (2) complied with (A) sections 38a-488c and 38a-514c, (B) sections 38a-488a and 38a-514, (C) sections 38a-510 and 38a-544, and (D) the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, P.L. 110-343, as amended from time to time, and regulations adopted thereunder.
(e) Nothing in this section shall be construed to require any disclosure in violation of (1) 42 USC 290dd-2, as amended from time to time, (2) 42 USC 1320d et seq., as amended from time to time, (3) 42 CFR 2, as amended from time to time, and (4) 45 CFR 160.101 to 164.534, inclusive, as amended from time to time.
(f) The Insurance Commissioner may adopt regulations, in accordance with chapter 54, to implement the provisions of this section.
(P.A. 19-159, S. 1; P.A. 24-81, S. 232; P.A. 25-94, S. 2.)
History: P.A. 24-81 amended Subsec. (c)(1)(B) by replacing “executive director of the Office of Health Strategy” with “Commissioner of Health Strategy”, effective May 30, 2024; P.A. 25-94 amended Subsec. (c) by deleting Subdiv. (1) designator, redesignating existing Subparas. (A) and (B) as Subdivs. (1) and (2) and deleting former Subdiv. (2) re confidentiality of name or identity of health carriers or entities contracting with health carriers.
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Sec. 38a-477oo. Certification of review of mental health and substance use disorder benefit reporting requirements. (a) As used in this section:
(1) “Health carrier” has the same meaning as provided in section 38a-1080; and
(2) “Mental health and substance use disorder benefits” has the same meaning as provided in section 38a-477ee.
(b) (1) Not later than March 1, 2026, and annually thereafter, each health carrier shall file a certification with the Insurance Commissioner for the immediately preceding calendar year, certifying that such health carrier completed a review of such health carrier's administrative practices for compliance with the state and federal mental health and substance use disorder benefit reporting requirements pursuant to sections 38a-477ee, 38a-488a, 38a-488c, 38a-488d, 38a-510, 38a-514, 38a-514c, 38a-514d and 38a-544 and the provisions of the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, P.L. 110-343, as amended from time to time, and regulations adopted thereunder.
(2) If such health carrier determines that such health carrier's administrative practices for the immediately preceding calendar year comply with the state and federal mental health and substance use disorder benefit reporting requirements identified in subdivision (1) of this subsection, such certification filed pursuant to subdivision (1) of this subsection shall state such finding.
(3) If such health carrier determines that such health carrier's administrative practices for the immediately preceding calendar year fail to comply with the state and federal mental health and substance use disorder benefit reporting requirements identified in subdivision (1) of this subsection, such certification filed pursuant to subdivision (1) of this subsection shall state such finding and identify (A) each administrative practice of such health carrier not in compliance with such state and federal mental health and substance use disorder benefit reporting requirements, and (B) action that such health carrier will take to bring such health carrier's administrative practices into compliance with such state and federal mental health and substance use disorder benefit reporting requirements.
(P.A. 25-94, S. 1.)
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Sec. 38a-477pp. Penalty for failure to comply with the mental health and substance use disorder benefit requirements. (a)(1) The commissioner, after providing an opportunity for a hearing in accordance with chapter 54, may impose a civil penalty on any health carrier of not more than one hundred dollars with respect to each participant or beneficiary covered under a health insurance policy of such health carrier, provided such penalty shall not exceed an aggregate amount of six hundred twenty-five thousand dollars annually, for such health carrier's failure to comply with (A) the certification requirements pursuant to the provisions of section 38a-477oo, (B) the state and federal mental health and substance use disorder benefit reporting requirements identified in subdivision (1) of subsection (b) of section 38a-477oo, or (C) any other requirement pursuant to sections 38a-477ee, 38a-488a, 38a-488c, 38a-488d, 38a-510, 38a-514, 38a-514c, 38a-514d and 38a-544 and the provisions of the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, P.L. 110-343, as amended from time to time, and regulations adopted thereunder.
(2) The commissioner may order the payment of such reasonable expenses as may be necessary to compensate the commissioner in conjunction with any proceedings under this section, which shall be dedicated to the enforcement and implementation of the state and federal mental health parity laws and regulations adopted thereunder.
(b) (1) If any health carrier fails to file any data, report, certification or other information required by the provisions of section 38a-477ee or section 38a-477oo, the commissioner shall impose a late fee on such health carrier of one hundred dollars per day from the due date of such filing of data, report, certification or information to the date such health carrier submits such filing to the commissioner, provided such late fee shall not exceed an aggregate amount of six hundred twenty-five thousand dollars.
(2) For any health carrier that files any incomplete data, report, certification or other information required by the provisions of section 38a-477ee and section 38a-477oo, the commissioner shall provide notice to such health carrier of such incomplete filing that includes (A) a description of such data, report, certification or other information that is incomplete and any additional data that is needed to consider such filing complete, and (B) the date by which such health carrier is required to provide such data. The commissioner shall impose a late fee on such health carrier of one hundred dollars per day, commencing from the date identified by the commissioner pursuant to subparagraph (B) of this subdivision, provided such late fee shall not exceed an aggregate amount of six hundred twenty-five thousand dollars.
(c) The commissioner may waive any civil penalty imposed pursuant to subsection (a) of this section if the commissioner determines that the violation was due to reasonable cause and was not due to wilful neglect, or if such violation is corrected not more than thirty days after the date that the health carrier filed a certification of noncompliance with the commissioner pursuant to section 38a-477oo.
(d) All civil penalties and late fees received by the commissioner pursuant to this section shall be deposited in the General Fund.
(e) The commissioner may engage the services of any health policy research organization or any other independent expert as the commissioner deems necessary to assist the commissioner in the review of any violation of the nonquantitative treatment limitations requirements pursuant to section 38a-477ee and the provisions of the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, P.L. 110-343, as amended from time to time, and regulations adopted thereunder.
(P.A. 25-94, S. 3.)
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Sec. 38a-477qq. (Note: This section is effective July 1, 2026.) Cost-sharing credits for out-of-pocket expenses. (a) As used in this section:
(1) “Enrollee” has the same meaning as provided in section 38a-478;
(2) “Health benefit plan” has the same meaning as provided in section 38a-472f; and
(3) “Health carrier” has the same meaning as provided in section 38a-591a.
(b) 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 a group health insurance policy or health benefit plan in this state on or after January 1, 2026, providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 in this state, shall, when calculating an insured's or enrollee's in-network liability for such insured's or enrollee's annual coinsurance, copayment, deductible or other in-network out-of-pocket expense, give credit for any out-of-pocket expense such insured or enrollee pays directly to any pharmacy licensed pursuant to section 20-594 or health care provider licensed in this state, for any prescription drug, provided (1) no claim for such prescription drug was submitted to such insurer, center, corporation, society or other entity, and (2) such out-of-pocket expense paid by such insured or enrollee to such pharmacy or health care provider is less than the average discounted rate for such prescription drug paid to an in-network health care provider pursuant to the terms of such health insurance policy or health benefit plan.
(c) If any insured or enrollee purchases a prescription drug from any out-of-network health care provider for a lower amount than the average amount paid by such insured's or enrollee's health carrier to any in-network health care provider for the same prescription drug, such health carrier, when calculating such insured's or enrollee's liability for such insured's or enrollee's in-network annual coinsurance, copayment, deductible or other out-of-pocket expense, shall give credit for such purchase, provided such insured or enrollee provides such health carrier with proof of payment for such prescription drug in accordance with the provisions of subsection (d) of this section. Nothing in this subsection shall be construed to restrict any health insurance policy or health benefit plan from requiring a prior authorization or precertification otherwise provided for in the insured's or enrollee's health insurance policy or health benefit plan.
(d) Each health carrier shall (1) develop a proof of payment form and publish such form on such health carrier's Internet web site for insureds and enrollees to submit proof of payment for any out-of-network prescription drug purchase pursuant to subsection (c) of this section, and (2) annually provide to such insureds and enrollees written notice of, and instructions for downloading or electronic submission of, such proof of payment form.
(e) Upon receipt of any such proof of payment form submitted by any insured or enrollee pursuant to subsection (d) of this section, each health carrier shall give credit for any out-of-pocket payments that such insured or enrollee paid to any out-of-network pharmacy or health care provider in accordance with the provisions of subsection (c) of this section, provided (1) the prescription drug purchased by such insured or enrollee is included under such insured's or enrollee's health insurance policy or health benefit plan, and (2) such insured or enrollee purchased such prescription drug for a lower price than the average amount paid by such insured or enrollee's health carrier to an in-network health care provider for the same prescription drug.
(f) The total amount credited toward any insured's or enrollee's annual coinsurance, copayment, deductible or other out-of-pocket expense pursuant to subsection (e) of this section shall not (1) exceed the total amount that such insured or enrollee is required to pay out-of-pocket under the terms of the health insurance policy or health benefit plan during a policy period, and (2) carry over to a new policy period.
(P.A. 25-167, S. 8.)
History: P.A. 25-167 effective July 1, 2026.
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Sec. 38a-479kkk. Duty of good faith and fair dealing. (a) Any pharmacy benefits manager shall exercise good faith and fair dealing in the performance of such pharmacy benefits manager's contractual duties to any health carrier, as defined in section 38a-591a, or other health benefit plan sponsor.
(b) Any pharmacy benefits manager shall notify the health carrier or other health benefit plan sponsor, in writing, of any activity, policy or practice of such pharmacy benefits manager that directly or indirectly presents any conflict of interest with the duties imposed by this section.
(c) Any pharmacy benefits manager shall have an obligation of good faith and fair dealing in performing such pharmacy benefits manager's duties with all parties, including, but not limited to, a health carrier or other health benefit plan sponsor with whom such pharmacy benefits manager interacts in the performance of pharmacy benefit management services.
(d) The Insurance Commissioner may adopt regulations, in accordance with the provisions of chapter 54, to implement the provisions of this section.
(P.A. 25-167, S. 1.)
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Sec. 38a-479ppp. Annual report by pharmacy benefits managers. Standardized form. Confidentiality of information. Penalty. Regulations. Commissioner's report to the General Assembly. (a) Not later than March 1, 2026, and annually thereafter, each pharmacy benefits manager shall file a report with the commissioner for the immediately preceding calendar year. The report shall contain the following information for health carriers that delivered, issued for delivery, renewed, amended or continued health care plans that included a pharmacy benefit managed by the pharmacy benefits manager during such calendar year:
(1) The aggregate dollar amount of all rebates concerning drug formularies used by such health carriers that such manager collected from pharmaceutical manufacturers that manufactured outpatient prescription drugs that (A) were covered by such health carriers during such calendar year, and (B) are attributable to patient utilization of such drugs during such calendar year; and
(2) The aggregate dollar amount of all rebates, excluding any portion of the rebates received by such health carriers, concerning drug formularies that such manager collected from pharmaceutical manufacturers that manufactured outpatient prescription drugs that (A) were covered by such health carriers during such calendar year, and (B) are attributable to patient utilization of such drugs by covered persons under such health care plans during such calendar year.
(b) The commissioner shall establish a standardized form for reporting information pursuant to subsection (a) of this section after consultation with pharmacy benefits managers. The form shall be designed to minimize the administrative burden and cost of reporting on the department and pharmacy benefits managers.
(c) All information submitted to the commissioner pursuant to subsection (a) of this section shall be exempt from disclosure under the Freedom of Information Act, as defined in section 1-200, except to the extent such information is included on an aggregated basis in the report required by subsection (d) of this section. The commissioner shall not disclose information submitted pursuant to subdivision (1) of subsection (a) of this section, or information submitted pursuant to subdivision (2) of said subsection in a manner that (1) is likely to compromise the financial, competitive or proprietary nature of such information, or (2) would enable a third party to identify a health care plan, health carrier, pharmacy benefits manager, pharmaceutical manufacturer, or the value of a rebate provided for a particular outpatient prescription drug or therapeutic class of outpatient prescription drugs.
(d) Not later than April 1, 2026, and annually thereafter, the commissioner shall submit a report, in accordance with section 11-4a, to the joint standing committee of the General Assembly having cognizance of matters relating to insurance. The report shall contain (1) an aggregation of the information submitted to the commissioner pursuant to subsection (a) of this section for the immediately preceding calendar year, and (2) such other information as the commissioner, in the commissioner's discretion, deems relevant for the purposes of this section. Not later than ten days prior to the submission of the annual report pursuant to the provisions of this subsection, the commissioner shall provide each pharmacy benefits manager and any third party affected by submission of such report required by this subsection with a written notice describing the content of the report.
(e) The commissioner may impose a penalty of not more than seven thousand five hundred dollars on a pharmacy benefits manager for each violation of this section.
(f) The commissioner may adopt regulations, in accordance with the provisions of chapter 54, to implement the provisions of this section.
(P.A. 18-41, S. 2; P.A. 24-138, S. 10; P.A. 25-132, S. 2.)
History: P.A. 18-41 effective January 1, 2020; P.A. 24-138 amended Subsec. (a) by substituting “February 1, 2025” for “March 1, 2021” re deadline for pharmacy benefits managers to submit annual report to commissioner, amended Subsec. (d) by substituting “March 1, 2025” for “March 1, 2022” and by substituting “ten days prior to the submission of the annual report” for “February 1, 2022, and annually thereafter” re deadline for commissioner to provide notice to pharmacy benefits manager and any third party affected by report to joint standing committee of the General Assembly having cognizance of matters relating to insurance and made technical changes, effective January 1, 2025; P.A. 25-132 amended Subsec. (a) by substituting “March 1, 2026” for “February 1, 2025”, and amended Subsec. (d) by substituting “April 1, 2026” for “March 1, 2025”, effective July 8, 2025.
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Sec. 38a-479ttt. Annual report by commissioner to the General Assembly re prescription drug rebates. Not later than March 1, 2021, and annually thereafter, the commissioner shall prepare a report, for the immediately preceding calendar year, describing the rebate practices of health carriers. The report shall contain (1) an explanation of the manner in which health carriers accounted for rebates in calculating premiums for health care plans delivered, issued for delivery, renewed, amended or continued during such year, (2) a statement disclosing whether, and describing the manner in which, health carriers made rebates available to insureds at the point of purchase during such year, (3) any other manner in which health carriers applied rebates during such year, (4) the percentage of rebate dollars used by health carriers to reduce premiums paid by insureds during such year, (5) an evaluation of rebate practices to reduce cost-sharing for health care plans delivered, issued for delivery, renewed, amended or continued during such year, and (6) such other information as the commissioner, in the commissioner's discretion, deems relevant for the purposes of this section. The commissioner shall publish a copy of the report on the department's Internet web site.
(P.A. 18-41, S. 6; P.A. 25-167, S. 3.)
History: P.A. 18-41 effective January 1, 2020; P.A. 25-167 added new Subdiv. (4) re percentage of rebate dollars used to reduce premiums, added Subdiv. (5) re evaluation of rebate practices to reduce cost-sharing, and redesignated existing Subdiv. (4) as Subdiv. (6).
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Sec. 38a-479uuu. Annual report by health carriers re pricing and profit generated. The Insurance Commissioner shall require any health carrier, as defined in section 38a-591a, to report to the commissioner annually on pricing in effect for the prior year and profit generated between such health carrier and any pharmacy benefits manager or mail-order pharmacy doing business with such health carrier, provided such information is reasonably available to such health carrier and any information noted by such health carrier as proprietary that is reported by such health carrier to the Insurance Commissioner pursuant to the provisions of this section shall be kept confidential by the Insurance Commissioner, in accordance with section 38a-69a.
(P.A. 25-167, S. 4.)
History: P.A. 25-167 effective January 1, 2026.
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Sec. 38a-481. (Formerly Sec. 38-165). *(See end of section for amended version of subsection (b) and effective date.) Filing of policy form, application, classification of risks and rates. Approval of rates. Prescription drug rebates. Medicare supplement policies: Age, gender, previous claim or medical history rating prohibited. Reduction of payments on basis of Medicare eligibility. Optional life insurance rider. Treatment of health insurance issued to association or certain other insurance arrangements. Special enrollment periods. Grandfathered and nongrandfathered plans. (a) No individual health insurance policy shall be delivered or issued for delivery to any person in this state, nor shall any application, rider or endorsement be used in connection with such policy, until a copy of the form thereof and of the classification of risks and the premium rates have been filed with the commissioner. Rate filings shall include the information and data required under section 38a-479qqq if the policy is subject to said section, and an actuarial memorandum that includes, but is not limited to, pricing assumptions and claims experience, and premium rates and loss ratios from the inception of the policy. Each premium rate filed on or after January 1, 2021, shall, if the insurer intends to account for rebates, as defined in section 38a-479ooo in the manner specified in section 38a-479rrr, account for such rebates in such manner, if the policy is subject to section 38a-479rrr. The commissioner may adopt regulations, in accordance with the provisions of chapter 54, to establish a procedure for reviewing such policies. The commissioner shall disapprove the use of such form at any time if it does not comply with the requirements of law, or if it contains a provision or provisions that are unfair or deceptive or that encourage misrepresentation of the policy. The commissioner shall notify, in writing, the insurer that has filed any such form of the commissioner's disapproval, specifying the reasons for disapproval, and ordering that no such insurer shall deliver or issue for delivery to any person in this state a policy on or containing such form. The provisions of section 38a-19 shall apply to such orders. As used in this subsection, “loss ratio” means the ratio of incurred claims to earned premiums by the number of years of policy duration for all combined durations.
*(b) No rate filed under the provisions of subsection (a) of this section shall be effective until it has been approved by the commissioner in accordance with regulations adopted pursuant to this subsection. The commissioner shall adopt regulations, in accordance with the provisions of chapter 54, to prescribe standards to ensure that such rates shall not be excessive, inadequate or unfairly discriminatory. The commissioner may disapprove such rate if it fails to comply with such standards, except that no rate filed under the provisions of subsection (a) of this section for any Medicare supplement policy shall be effective unless approved in accordance with section 38a-474.
(c) No insurance company, fraternal benefit society, hospital service corporation, medical service corporation, health care center or other entity that delivers or issues for delivery in this state any Medicare supplement policies or certificates shall incorporate in its rates or determinations to grant coverage for Medicare supplement insurance policies or certificates any factors or values based on the age, gender, previous claims history or the medical condition of any person covered by such policy or certificate.
(d) No individual health insurance policy delivered, issued for delivery, renewed, amended or continued in this state shall include any provision that reduces payments on the basis that an individual is eligible for Medicare by reason of age, disability or end-stage renal disease, unless such individual enrolls in Medicare. If such individual enrolls in Medicare, any such reduction shall be only to the extent such coverage is provided by Medicare.
(e) Nothing in this chapter shall preclude the issuance of an individual health insurance policy that includes an optional life insurance rider, provided the optional life insurance rider shall be filed with and approved by the Insurance Commissioner pursuant to section 38a-430. Any company offering such policies for sale in this state shall be licensed to sell life insurance in this state pursuant to the provisions of section 38a-41.
(f) Health insurance issued to an association or other insurance arrangement that is not made up solely of employer groups shall be treated as individual health insurance.
(g) (1) As used in this subsection, “Affordable Care Act” means the Patient Protection and Affordable Care Act, P.L. 111-148, as amended from time to time, and regulations adopted thereunder, and “grandfathered plan” has the same meaning as “grandfathered health plan” as provided in the Affordable Care Act.
(2) Each individual health insurance policy subject to the Affordable Care Act shall (A) be offered on a guaranteed issue basis with respect to all eligible individuals or dependents, and (B) provide special enrollment periods to (i) all eligible individuals or dependents as set forth in 45 CFR 147.104, as amended from time to time, and (ii) all eligible pregnant individuals not more than thirty days after the commencement of the pregnancy, as certified by any licensed health care provider acting within the scope of such health care provider's practice. Coverage under subparagraph (B)(ii) of this subdivision shall be (I) effective on the first of the month in which the individual receives such certification, and (II) limited to eligible individuals who do not have, at a minimum, essential benefits as determined under the Affordable Care Act or the coverage requirements under chapter 700c. Nothing in this subdivision shall be construed to prohibit any person from enrolling in an individual health insurance policy offered or sold through the exchange or not offered or sold through the exchange.
(3) With respect to grandfathered plans of a policy under subdivision (2) of this subsection, the premium rates charged or offered shall be established on the basis of a single pool of all grandfathered plans.
(4) With respect to nongrandfathered plans of a policy under subdivision (2) of this subsection:
(A) The premium rates charged or offered shall be established on the basis of a single pool of all nongrandfathered plans, adjusted to reflect one or more of the following classifications:
(i) Age, in accordance with a uniform age rating curve established by the commissioner;
(ii) Geographic area, as defined by the commissioner;
(iii) Tobacco use, except that such rate may not vary by a ratio of greater than 1.5 to 1.0 and may only be applied with respect to individuals who may legally use tobacco under state and federal law. For purposes of this subparagraph, “tobacco use” means the use of tobacco products four or more times per week on average within a period not longer than the six months immediately preceding. “Tobacco use” does not include the religious or ceremonial use of tobacco;
(B) Total premium rates for family coverage shall be determined by adding the premiums for each individual family member, except that with respect to family members under twenty-one years of age, the premiums for only the three oldest covered children shall be taken into account in determining the total premium rate for such family.
(5) Premium rates for a grandfathered or nongrandfathered policy under subdivision (2) of this subsection may vary by (A) actuarially justified differences in plan design, and (B) actuarially justified amounts to reflect the policy's provider network and administrative expense differences that can be reasonably allocated to such policy.
(1949 Rev., S. 6177; 1951, S. 2835d; 1967, P.A. 437, S. 1; P.A. 78-280, S. 6, 127; P.A. 88-230, S. 1, 12; 88-326, S. 4; P.A. 90-243, S. 72; P.A. 91-311; P.A. 93-390, S. 5, 8; P.A. 96-51, S. 2; P.A. 03-119, S. 1; P.A. 05-20, S. 3; P.A. 09-123, S. 1; P.A. 10-5, S. 18; P.A. 11-19, S. 29; P.A. 12-145, S. 11; P.A. 13-149, S. 1; P.A. 14-235, S. 55; P.A. 15-118, S. 50; 15-247, S. 6; P.A. 18-41, S. 8; 18-43, S. 2.)
*Note: On and after January 1, 2027, subsection (b) of this section, as amended by section 6 of public act 25-94, is to read as follows:
“(b) No rate filed under the provisions of subsection (a) of this section shall be effective until it has been approved by the commissioner in accordance with regulations adopted pursuant to this subsection. The commissioner shall adopt regulations, in accordance with the provisions of chapter 54, to prescribe standards to ensure that such rates shall not be excessive, inadequate or unfairly discriminatory. The commissioner may disapprove such rate if it fails to comply with such standards, except that no rate filed under the provisions of subsection (a) of this section for any Medicare supplement policy shall be effective unless approved in accordance with section 38a-474. If the commissioner determines that a health carrier's average premium rate increase, as approved by the commissioner, exceeded the health care cost growth benchmark established pursuant to section 19a-754g for each of the two most recent plan years for which such health care cost growth benchmark data is available, the commissioner may reduce such health carrier's requested rate filed under the provisions of subsection (a) of this section by not more than two percentage points of such premium rate filed in addition to any other rate reductions authorized under this title.”
(1949 Rev., S. 6177; 1951, S. 2835d; 1967, P.A. 437, S. 1; P.A. 78-280, S. 6, 127; P.A. 88-230, S. 1, 12; 88-326, S. 4; P.A. 90-243, S. 72; P.A. 91-311; P.A. 93-390, S. 5, 8; P.A. 96-51, S. 2; P.A. 03-119, S. 1; P.A. 05-20, S. 3; P.A. 09-123, S. 1; P.A. 10-5, S. 18; P.A. 11-19, S. 29; P.A. 12-145, S. 11; P.A. 13-149, S. 1; P.A. 14-235, S. 55; P.A. 15-118, S. 50; 15-247, S. 6; P.A. 18-41, S. 8; 18-43, S. 2; P.A. 25-94, S. 6.)
History: 1967 act added Subsec. (b) re effective date of rates and rate standards; P.A. 78-280 replaced “Hartford county” with “judicial district of Hartford-New Britain” in Subsec. (a); P.A. 88-230 proposed to replace reference to “judicial district of Hartford-New Britain” with “judicial district of Hartford”, effective September 1, 1991, but said reference was deleted by P.A. 88-326; P.A. 88-326 required the commissioner to adopt regulations establishing a procedure for policy review and rephrased existing provisions; P.A. 90-243 substituted reference to “individual health insurance policy” for references to insurance against loss from sickness, bodily injury or accidental death; Sec. 38-165 transferred to Sec. 38a-481 in 1991; P.A. 91-311 amended Subsec. (b) to exclude Medicare supplement policy rates unless filed in accordance with Sec. 38a-474, added a new Subsec. (c) re filing of the required loss ratio guarantee form to preclude the claim that a particular policy has excessive rates and added the discretionary authority for the commissioner to adopt regulations re the terms of the loss ratio guarantee, added a new Subsec. (d) re premium rates if filed with a loss ratio guarantee and outlining the minimum requirements of a loss ratio guarantee in order to meet the commissioner's approval, the refund procedure for Connecticut policyholders and the procedures by which a policy form can be withdrawn and added Subsec. (e) defining “loss ratio” and “experience period”; P.A. 93-390 inserted new Subsec. (c) prohibiting the incorporation of factors for age, gender, previous claim or medical condition history into the insurer's rate schedule and relettered the remaining Subsecs. and internal references accordingly, effective January 1, 1994; P.A. 96-51 added Subsec. (g) to permit optional life insurance riders; P.A. 03-119 added Subsec. (h) re underwriting classifications; P.A. 05-20 made technical changes and amended provisions re regulations throughout, amended Subsec. (c) re Medicare supplements to reference “determinations to grant coverage” and plans “H” to “J”, inclusive, “issued prior to January 1, 2006,” re use of claims history and medical condition, amended Subsec. (d) to insert Subdiv. designators (1) and (2), and amended Subsec. (e)(5) to delete provisions re donations to Uncas-on-Thames Hospital, effective July 1, 2005; P.A. 09-123 amended Subsec. (h) by adding Subdiv. (3) prohibiting use of certain prescription drug history of an individual in underwriting and making technical changes, effective January 1, 2010; P.A. 10-5 made a technical change in Subsec. (b), effective May 5, 2010; P.A. 11-19 amended Subsec. (c) to delete provisions re Medicare supplement plans “H” to “J”; P.A. 12-145 made a technical change in Subsec. (d), effective June 15, 2012; P.A. 13-149 amended Subsec. (a) by adding provision requiring for rate filings an actuarial memorandum that includes pricing assumptions and claims experience, premium rates and loss ratios from inception of the policy, amended Subsec. (b) by deleting provision re 30-day period after which policy is deemed approved, deleted former Subsecs. (d) and (e) re loss ratio guarantee, redesignated existing Subsecs. (f), (g) and (h) as Subsecs. (d), (e) and (f), and made technical changes in redesignated Subsec. (e), effective June 21, 2013; P.A. 14-235 amended Subsec. (d) to delete former Subdiv. (2) re definition of “experience period” and make conforming changes; P.A. 15-118 made technical changes in Subsecs. (a) to (c); P.A. 15-247 amended Subsec. (a) by adding definition of “loss ratio”, amended Subsec. (b) by deleting provision re 30-day period for disapproval of rate, amended Subsec. (d) by deleting definition of “loss ratio” and adding provision re reduction of payments on basis of Medicare eligibility, deleted former Subsec. (f) re prohibited underwriting practices, added new Subsec. (f) re treatment of health insurance issued to association or other insurance arrangement as individual health insurance, added Subsec. (g) re requirements for individual policies subject to Affordable Care Act and grandfathered and nongrandfathered plans, and made technical and conforming changes, effective July 10, 2015; P.A. 18-41 amended Subsec. (a) by adding provisions re inclusion of information and data required under Sec. 38a-479qqq and accounting for rebates in manner specified in Sec. 38a-479rrr and replacing “shall” with “may” re commissioner's authority to adopt regulations, effective January 1, 2020; P.A. 18-43 amended Subsec. (g)(2) by designating existing provision re policies subject to Affordable Care Act be offered on guaranteed issue basis with respect to all eligible individuals or dependents as Subpara. (A), adding Subpara. (B) re special enrollment periods, and adding provisions re coverage under Subpara. (B) and enrollment in individual health insurance policy, effective January 1, 2019; P.A. 25-94 amended Subsec. (b) by adding provision re commissioner may reduce requested rate filed if commissioner determines that the average premium rate increase exceeded the health care cost growth benchmark for each of the two most recent plan years, effective January 1, 2027.
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Sec. 38a-488b. *(See end of section for amended version of subdivision (4) of subsection (a) and effective date.) Coverage for autism spectrum disorder therapies. (a) As used in this section:
(1) “Applied behavior analysis” means the design, implementation and evaluation of environmental modifications, using behavioral stimuli and consequences, including the use of direct observation, measurement and functional analysis of the relationship between environment and behavior, to produce socially significant improvement in human behavior.
(2) “Autism spectrum disorder services provider” means any person, entity or group that provides treatment for an autism spectrum disorder pursuant to this section.
(3) “Autism spectrum disorder” means “autism spectrum disorder” as set forth in the most recent edition of the American Psychiatric Association's “Diagnostic and Statistical Manual of Mental Disorders”.
*(4) “Behavioral therapy” means any interactive behavioral therapies derived from evidence-based research and consistent with the services and interventions designated by the Commissioner of Social Services pursuant to subsection (e) of section 17a-215c, including, but not limited to, applied behavior analysis, cognitive behavioral therapy, or other therapies supported by empirical evidence of the effective treatment of individuals diagnosed with autism spectrum disorder, that are: (A) Provided to children less than twenty-one years of age; and (B) provided or supervised by (i) a licensed behavior analyst, (ii) a licensed physician, or (iii) a licensed psychologist. For the purposes of this subdivision, behavioral therapy is “supervised by” such licensed behavior analyst, licensed physician or licensed psychologist when such supervision entails at least one hour of face-to-face supervision of the autism spectrum disorder services provider by such licensed behavior analyst, licensed physician or licensed psychologist for each ten hours of behavioral therapy provided by the supervised provider.
(5) “Diagnosis” means the medically necessary assessment, evaluation or testing performed by a licensed physician, licensed psychologist or licensed clinical social worker to determine if an individual has autism spectrum disorder.
(b) Each individual 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 shall provide coverage for the diagnosis and treatment of autism spectrum disorder. For the purposes of this section and section 38a-482a, autism spectrum disorder shall be considered an illness.
(c) Such policy shall provide coverage for the following treatments, provided such treatments are (1) medically necessary, and (2) identified and ordered by a licensed physician, licensed psychologist or licensed clinical social worker for an insured who is diagnosed with autism spectrum disorder, in accordance with a treatment plan developed by a licensed behavior analyst, licensed physician, licensed psychologist or licensed clinical social worker, pursuant to a comprehensive evaluation or reevaluation of the insured:
(A) Behavioral therapy;
(B) Prescription drugs, to the extent prescription drugs are a covered benefit for other diseases and conditions under such policy, prescribed by a licensed physician, a licensed physician assistant or an advanced practice registered nurse for the treatment of symptoms and comorbidities of autism spectrum disorder;
(C) Direct psychiatric or consultative services provided by a licensed psychiatrist;
(D) Direct psychological or consultative services provided by a licensed psychologist;
(E) Physical therapy provided by a licensed physical therapist;
(F) Speech and language pathology services provided by a licensed speech and language pathologist; and
(G) Occupational therapy provided by a licensed occupational therapist.
(d) Such policy shall not impose (1) any limits on the number of visits an insured may make to an autism spectrum disorder services provider pursuant to a treatment plan on any basis other than a lack of medical necessity, or (2) a coinsurance, copayment, deductible or other out-of-pocket expense for such coverage that places a greater financial burden on an insured for access to the diagnosis and treatment of autism spectrum disorder than for the diagnosis and treatment of any other medical, surgical or physical health condition under such policy.
(e) (1) Except for treatments and services received by an insured in an inpatient setting, an insurer, health care center, hospital service corporation, medical service corporation or fraternal benefit society may review a treatment plan developed as set forth in subsection (c) of this section for such insured, in accordance with its utilization review requirements, not more than once every six months unless such insured's licensed physician, licensed psychologist or licensed clinical social worker agrees that a more frequent review is necessary or changes such insured's treatment plan.
(2) For the purposes of this section, the results of a diagnosis shall be valid for a period of not less than twelve months, unless such insured's licensed physician, licensed psychologist or licensed clinical social worker determines a shorter period is appropriate or changes the results of such insured's diagnosis.
(f) Coverage required under this section may be subject to the other general exclusions and limitations of the individual health insurance policy, including, but not limited to, coordination of benefits, participating provider requirements, restrictions on services provided by family or household members and case management provisions, except that any utilization review shall be performed in accordance with subsection (e) of this section.
(g) (1) Nothing in this section shall be construed to limit or affect (A) any other covered benefits available to an insured under (i) such individual health insurance policy, (ii) section 38a-488a, or (iii) section 38a-490a, (B) any obligation to provide services to an individual under an individualized education program pursuant to section 10-76d, or (C) any obligation imposed on a public school by the Individual With Disabilities Education Act, 20 USC 1400 et seq., as amended from time to time.
(2) Nothing in this section shall be construed to require such individual health insurance policy to provide reimbursement for special education and related services provided to an insured pursuant to section 10-76d, unless otherwise required by state or federal law.
(P.A. 08-132, S. 1; P.A. 11-4, S. 6; P.A. 13-84, S. 1; June Sp. Sess. P.A. 15-5, S. 348; May Sp. Sess. P.A. 16-3, S. 55; June Sp. Sess. P.A. 17-2, S. 197; P.A. 23-204, S. 280.)
*Note: On and after January 1, 2027, subdivision (4) of subsection (a) of this section, as amended by section 6 of public act 25-3 of the November special session, is to read as follows:
“(4) “Behavioral therapy” means any interactive behavioral therapies derived from evidence-based research and consistent with the services and interventions designated by the Commissioner of Social Services pursuant to subsection (e) of section 17a-215c, including, but not limited to, applied behavior analysis, cognitive behavioral therapy, or other therapies supported by empirical evidence of the effective treatment of individuals diagnosed with autism spectrum disorder, that are: (A) Provided to individuals under twenty-six years of age; and (B) provided or supervised by (i) a licensed behavior analyst, (ii) a licensed physician, or (iii) a licensed psychologist. For the purposes of this subdivision, behavioral therapy is “supervised by” such licensed behavior analyst, licensed physician or licensed psychologist when such supervision entails at least one hour of face-to-face supervision of the autism spectrum disorder services provider by such licensed behavior analyst, licensed physician or licensed psychologist for each ten hours of behavioral therapy provided by the supervised provider.”
(P.A. 08-132, S. 1; P.A. 11-4, S. 6; P.A. 13-84, S. 1; June Sp. Sess. P.A. 15-5, S. 348; May Sp. Sess. P.A. 16-3, S. 55; June Sp. Sess. P.A. 17-2, S. 197; P.A. 23-204, S. 280; Nov. Sp. Sess. P.A. 25-3, S. 6.)
History: P.A. 08-132 effective January 1, 2009; P.A. 11-4 substituted “autism spectrum disorder” for “autism spectrum disorders”, effective May 9, 2011; P.A. 13-84 designated existing provisions as Subsec. (a) and amended same by adding provision re coverage for insured diagnosed with autism spectrum disorder prior to release of the fifth edition of the American Psychiatric Association's “Diagnostic and Statistical Manual of Mental Disorders” and by making a technical change, and added Subsec. (b) re same coverage provision, effective June 5, 2013; June Sp. Sess. P.A. 15-5 added new Subsec. (a) defining “applied behavior analysis”, “autism spectrum disorder services provider”, “autism spectrum disorder”, “behavioral therapy”, and “diagnosis”, redesignated existing Subsec. (a) as Subsec. (b) and amended same to add “diagnosis and”, delete references to physical therapy, speech therapy and occupational therapy services and the American Psychiatric Association's “Diagnostic and Statistical Manual of Mental Disorders”, delete provisions re limitation on coverage and add provision re autism spectrum disorder to be considered an illness, deleted former Subsec. (b) re maintaining coverage, added Subsec. (c) re coverage for treatments, added Subsec. (d) re prohibition on imposing limits on visits or out-of-pocket expenses, added Subsec. (e) re review of treatment plan and time period of validity of diagnostic results, added Subsec. (f) re exclusions from and limitations on coverage, and added Subsec. (g) re other covered benefits, obligations to provide services and obligations imposed on public schools and re reimbursement for special education and related services, effective January 1, 2016; May Sp. Sess. P.A. 16-3 amended Subsec. (a)(4) to replace “Commissioner of Developmental Services” with “Commissioner of Social Services”, effective July 1, 2016; June Sp. Sess. P.A. 17-2 amended Subsecs. (a)(4) and (c) to add references to licensed behavior analyst and delete references to certification of behavior analyst by Behavior Analyst Certification Board, effective July 1, 2018; P.A. 23-204 amended Subsec. (a)(4) by replacing reference to Sec. 17a-215c(l) with reference to Sec. 17a-215c(e), effective July 1, 2023; Nov. Sp. Sess. P.A. 25-3 amended Subsec. (a)(4)(A) by changing coverage age from under age 21 to under age 26, effective January 1, 2027.
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Sec. 38a-492w. Medically necessary wheelchair repairs, replacements. Coverage requirements. (a) As used in this section, (1) “complex rehabilitation technology wheelchair” has the same meaning as provided in section 42-337, and (2) “medically necessary” means a written determination by a policy holder's health care provider that repair or replacement of a complex rehabilitation technology wheelchair is necessary to preserve the health of such policy holder.
(b) Each individual health insurance policy providing coverage of the types 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 and after January 1, 2025, shall not require a new prescription or prior authorization for the medically necessary repair or replacement of a complex rehabilitation technology wheelchair unless the original prescription is more than five years old.
(c) The Insurance Commissioner may adopt regulations, in accordance with chapter 54, to implement the provisions of this section.
(P.A. 24-58, S. 5; P.A. 25-132, S. 3.)
History: P.A. 24-58 effective July 1, 2024; P.A. 25-132 amended Subsec. (c) by replacing “shall” with “may” re commissioner's authority to adopt regulations, effective July 8, 2025.
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Sec. 38a-492y. Mandatory coverage for biomarker testing. (a) As used in this section:
(1) “Biomarker” means a characteristic, including, but not limited to, a gene mutation or protein expression that can be objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes or pharmacologic responses to a specific therapeutic intervention for a disease or condition.
(2) “Biomarker testing” means the analysis of a patient's tissue, blood or other biospecimen for the presence of a biomarker, including, but not limited to, tests for a single substance, tests for multiple substances and diseases or conditions. “Biomarker testing” does not include an evaluation of how a patient feels, functions or survives.
(3) “Clinical utility” means the test result provides information that is used in the formulation of a treatment or monitoring strategy that informs a patient's outcome and impacts the clinical decision.
(4) “Nationally recognized clinical practice guidelines” means evidence-based clinical practice guidelines informed by a systematic review of evidence and an assessment of the benefits and risks of alternative care options intended to optimize patient care developed by independent organizations or medical professional societies utilizing transparent methodologies and reporting structures and conflict-of-interest policies.
(b) 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 on or after January 1, 2026, shall provide coverage for biomarker testing for the purpose of diagnosis, treatment, appropriate management or ongoing monitoring of an insured's disease or condition, provided such biomarker testing provides clinical utility as demonstrated by medical and scientific evidence, including, but not limited to, one or more of the following: (1) Approval or clearance of such test by the federal Food and Drug Administration or recommendations on labels of drugs approved by the federal Food and Drug Administration to conduct such test, (2) national coverage determinations or local coverage determinations for Medicare Administrative Contractors by the Centers for Medicare and Medicaid Services, or (3) nationally recognized clinical practice guidelines. Such policy shall provide such coverage in a manner that limits disruptions in care, including, but not limited to, the need for multiple biopsies or biospecimen samples. Such policy may require that biomarker testing be performed at an in-network clinical laboratory, as defined in section 19a-490.
(c) Each entity providing such coverage shall establish a clear, readily accessible and convenient process through which an insured or an insured's health care provider may (1) request an exception to a coverage policy, or (2) dispute an adverse utilization review determination relating to such coverage. Each such entity shall post such process on the Internet web site maintained by such entity.
(d) If prior authorization is required before providing such coverage, each entity providing such coverage or each utilization review entity or other third party acting on behalf of such entity shall approve or deny such prior authorization and notify the insured, the insured's health care provider and any other entity requesting such prior authorization of such approval or denial (1) if the prior authorization is not urgent, as determined by the insured's health care provider, not later than seven days after receiving a prior authorization request, or (2) if the prior authorization is urgent, as determined by the insured's health care provider, not later than seventy-two hours after receiving a prior authorization request.
(P.A. 25-16, S. 4.)
History: P.A. 25-16 effective January 1, 2026.
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Sec. 38a-498a. Prior authorization prohibited for certain 9-1-1 emergency calls or transporting enrollee to a hospital by ambulance when medically necessary. Denial of payment to ambulance provider responding to 9-1-1 local prehospital emergency medical service system call prohibited on basis that enrollee did not obtain approval prior to calling such system or transporting such enrollee when medically necessary by ambulance to a hospital. (a) No individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469 and delivered, issued for delivery or renewed in this state, on or after January 1, 2025, shall direct or require an enrollee to obtain approval from the insurer or health care center prior to (1) calling a 9-1-1 local prehospital emergency medical service system whenever such enrollee is confronted with a life or limb threatening emergency, or (2) transporting such enrollee when medically necessary by ambulance to a hospital. For purposes of this section, a “life or limb threatening emergency” means any event which the enrollee believes threatens such enrollee's life or limb in such a manner that a need for immediate medical care is created to prevent death or serious impairment of health.
(b) No insurer or health care center subject to the provisions of subsection (a) of this section shall deny payment to any ambulance provider responding to a 9-1-1 local prehospital emergency medical service system call on the basis that the enrollee did not obtain approval from such insurer or health care center prior to calling such emergency medical service system or prior to transporting such enrollee when medically necessary by ambulance to a hospital.
(P.A. 96-67, S. 1; P.A. 24-19, S. 34; P.A. 25-97, S. 41.)
History: (Revisor's note: In codifying public act 96-67 an incorrect reference to “of subsection (a)” appearing before the reference to “section 38a-469” was deleted editorially by the Revisors); P.A. 24-19 designated existing provisions as Subsec. (a) and amended same by replacing “October 1, 1996” with “January 1, 2025”, inserting Subdiv. (1) designator and adding Subdiv. (2) prohibiting prior approval for transporting enrollee to hospital by ambulance when medically necessary and added Subsec. (b) prohibiting denial of payment to ambulance provider responding to 9-1-1 local prehospital emergency medical service system call on basis that enrollee did not obtain approval prior to calling such system or transporting such enrollee when medically necessary by ambulance to hospital, effective January 1, 2025; P.A. 25-97 amended Subsec. (a) by making a technical change.
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Sec. 38a-499b. Reimbursement for general anesthesia re time limit restrictions. (a) As used in this section:
(1) “General anesthesia” has the same meaning as provided in section 20-123a; and
(2) “Medically necessary” has the same meaning as provided in section 38a-482a.
(b) 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 on or after January 1, 2026, shall, if such policy provides coverage for general anesthesia, (1) impose an arbitrary time limit on reimbursement for general anesthesia provided during any medically necessary procedure, or (2) deny, reduce, terminate or fail to provide such reimbursement, in whole or in part, for general anesthesia solely because the duration of care exceeded a predetermined time limit as determined by the insurer.
(P.A. 25-94, S. 8.)
History: P.A. 25-94 effective January 1, 2026.
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Sec. 38a-510. Prescription drug coverage. Mail order pharmacies. Step therapy use. (a) No insurance company, hospital service corporation, medical service corporation, health care center or other entity delivering, issuing for delivery, renewing, amending or continuing an individual health insurance policy or contract that provides coverage for prescription drugs may:
(1) Require any person covered under such policy or contract to obtain prescription drugs from a mail order pharmacy as a condition of obtaining benefits for such drugs; or
(2) Require, if such insurance company, hospital service corporation, medical service corporation, health care center or other entity uses step therapy for such drugs, the use of step therapy (A) for any prescribed drug for longer than thirty days, (B) for a prescribed drug for cancer treatment for an insured who has been diagnosed with stage IV metastatic cancer, multiple sclerosis or rheumatoid arthritis, provided such prescribed drug is in compliance with approved federal Food and Drug Administration indications, or (C) for the treatment of schizophrenia, major depressive disorder or bipolar disorder, as defined in the most recent edition of the American Psychiatric Association's “Diagnostic and Statistical Manual of Mental Disorders”.
(3) At the expiration of the time period specified in subparagraph (A) of subdivision (2) of this subsection or for a prescribed drug described in subparagraph (B) or (C) of subdivision (2) of this subsection, an insured's treating health care provider may deem such step therapy drug regimen clinically ineffective for the insured, at which time the insurance company, hospital service corporation, medical service corporation, health care center or other entity shall authorize dispensation of and coverage for the drug prescribed by the insured's treating health care provider, provided such drug is a covered drug under such policy or contract. If such provider does not deem such step therapy drug regimen clinically ineffective or has not requested an override pursuant to subdivision (1) of subsection (b) of this section, such drug regimen may be continued. For purposes of this section, “step therapy” means a protocol or program that establishes the specific sequence in which prescription drugs for a specified medical condition are to be prescribed.
(b) (1) Notwithstanding the thirty-day period set forth in subparagraph (A) of subdivision (2) of subsection (a) of this section, each insurance company, hospital service corporation, medical service corporation, health care center or other entity that uses step therapy for such prescription drugs shall establish and disclose to its health care providers a process by which an insured's treating health care provider may request at any time an override of the use of any step therapy drug regimen. Any such override process shall be convenient to use by health care providers and an override request shall be expeditiously granted when an insured's treating health care provider demonstrates that the drug regimen required under step therapy (A) has been ineffective in the past for treatment of the insured's medical condition, (B) is expected to be ineffective based on the known relevant physical or mental characteristics of the insured and the known characteristics of the drug regimen, (C) will cause or will likely cause an adverse reaction by or physical harm to the insured, or (D) is not in the best interest of the insured, based on medical necessity.
(2) Upon the granting of an override request, the insurance company, hospital service corporation, medical service corporation, health care center or other entity shall authorize dispensation of and coverage for the drug prescribed by the insured's treating health care provider, provided such drug is a covered drug under such policy or contract.
(c) Nothing in this section shall (1) preclude an insured or an insured's treating health care provider from requesting a review under sections 38a-591c to 38a-591g, inclusive, or (2) affect the provisions of section 38a-492i.
(P.A. 05-233, S. 1; P.A. 14-118, S. 1; P.A. 17-228, S. 1; P.A. 23-204, S. 225; P.A. 25-94, S. 4.)
History: P.A. 05-233 effective July 1, 2005; P.A. 14-118 amended Subsec. (a) to designate existing provision re mail order pharmacy as Subdiv. (1) and add Subdiv. (2) re step therapy, deleted former Subsec. (b) re application of section, added new Subsec. (b) re step therapy override, added Subsec. (c) re effect of section on Secs. 38a-591c to 38a-591g and 38a-492i, and made technical and conforming changes, effective January 1, 2015; P.A. 17-228 amended Subsec. (a) to designate existing provisions re prescribed drug for longer than 60 days as Subpara. (A), and add Subpara. (B) re prescribed drug for cancer treatment in Subdiv. (2), designate existing provisions re deeming step therapy drug regimen clinically ineffective as Subdiv. (3) and amended same to add reference to Subdiv. (2), and make technical changes, effective January 1, 2018; P.A. 23-204 amended Subsec. (a) by substituting 30 days for 60 days in Subdiv. (2)(A), adding Subdiv. (2)(C) re step therapy prescription drug prohibition for treatment of schizophrenia, major depressive disorder and bipolar disorder from January 1, 2024, to January 1, 2027, and made technical and conforming changes, effective January 1, 2024; P.A. 25-94 amended Subsec. (a)(2)(B) re step therapy prescription drug prohibition for treatment of multiple sclerosis and rheumatoid arthritis, amended Subsec. (a)(2)(C) by deleting “for the period commencing January 1, 2024, and ending January 1, 2027, inclusive”, and amended Subsec. (b)(1) by substituting 30 days for 60 days and making a technical change, effective January 1, 2026.
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Sec. 38a-513. *(See end of section for amended version of subsection (a) and effective date.) Approval of policy forms and small employer rates. Prescription drug rebates. Medicare supplement policies. Age, gender, previous claim or medical history rating prohibited. Optional life insurance rider. Group specified disease policies. *(a)(1) No group health insurance policy, as defined by the commissioner, or certificate shall be delivered or issued for delivery in this state unless a copy of the form for such policy or certificate has been submitted to and approved by the commissioner under the regulations adopted pursuant to this section. The commissioner shall adopt regulations, in accordance with the provisions of chapter 54, concerning the provisions, submission and approval of such policies and certificates and establishing a procedure for reviewing such policies and certificates. The commissioner shall disapprove the use of such form at any time if it does not comply with the requirements of law, or if it contains a provision or provisions that are unfair or deceptive or that encourage misrepresentation of the policy. The commissioner shall notify, in writing, the insurer that has filed any such form of the commissioner's disapproval, specifying the reasons for disapproval, and ordering that no such insurer shall deliver or issue for delivery to any person in this state a policy on or containing such form. The provisions of section 38a-19 shall apply to such order.
(2) No group health insurance policy or certificate for a small employer, as defined in section 38a-564, shall be delivered or issued for delivery in this state unless the premium rates have been submitted to and approved by the commissioner. Premium rate filings shall include the information and data required under section 38a-479qqq if the policy is subject to said section, and an actuarial memorandum that includes, but is not limited to, pricing assumptions and claims experience, and premium rates and loss ratios from the inception of the policy. Each premium rate filed on or after January 1, 2021, shall, if the insurer intends to account for rebates, as defined in section 38a-479ooo in the manner specified in section 38a-479rrr, account for such rebates in such manner, if the policy is subject to section 38a-479rrr. As used in this subdivision, “loss ratio” means the ratio of incurred claims to earned premiums by the number of years of policy duration for all combined durations.
(b) No insurance company, fraternal benefit society, hospital service corporation, medical service corporation, health care center or other entity that delivers or issues for delivery in this state any Medicare supplement policies or certificates shall incorporate in its rates or determinations to grant coverage for Medicare supplement insurance policies or certificates any factors or values based on the age, gender, previous claims history or the medical condition of any person covered by such policy or certificate.
(c) Nothing in this chapter shall preclude the issuance of a group health insurance policy that includes an optional life insurance rider, provided the optional life insurance rider shall be filed with and approved by the Insurance Commissioner pursuant to section 38a-430. Any company offering such policies for sale in this state shall be licensed to sell life insurance in this state pursuant to the provisions of section 38a-41.
(d) Not later than January 1, 2009, the commissioner shall adopt regulations, in accordance with chapter 54, to establish minimum standards for benefits in group specified disease policies, certificates, riders, endorsements and benefits.
(P.A. 90-243, S. 97; P.A. 93-390, S. 7, 8; P.A. 96-51, S. 3; P.A. 05-20, S. 6; P.A. 08-181, S. 6; P.A. 11-19, S. 32; P.A. 14-235, S. 28; P.A. 15-118, S. 51; 15-247, S. 7; P.A. 18-41, S. 9.)
*Note: On and after January 1, 2027, subsection (a) of this section, as amended by section 7 of public act 25-94, is to read as follows:
“(a)(1) No group health insurance policy, as defined by the commissioner, or certificate shall be delivered or issued for delivery in this state unless a copy of the form for such policy or certificate has been submitted to and approved by the commissioner under the regulations adopted pursuant to this section. The commissioner shall adopt regulations, in accordance with the provisions of chapter 54, concerning the provisions, submission and approval of such policies and certificates and establishing a procedure for reviewing such policies and certificates. The commissioner shall disapprove the use of such form at any time if it does not comply with the requirements of law, or if it contains a provision or provisions that are unfair or deceptive or that encourage misrepresentation of the policy. The commissioner shall notify, in writing, the insurer that has filed any such form of the commissioner's disapproval, specifying the reasons for disapproval, and ordering that no such insurer shall deliver or issue for delivery to any person in this state a policy on or containing such form. The provisions of section 38a-19 shall apply to such order.
(2) No group health insurance policy or certificate for a small employer, as defined in section 38a-564, shall be delivered or issued for delivery in this state unless the premium rates have been submitted to and approved by the commissioner. If the commissioner determines that any small group health insurance carrier's average premium rate increase, as approved by the commissioner, or certificate for a small employer, exceeded the health care cost growth benchmark established pursuant to section 19a-754g for each of the two most recent plan years for which such health care cost growth benchmark data is available, the commissioner may reduce such policy's or certificate's requested premium rate filing under the provisions of this subsection by not more than two percentage points of such premium rate filed in addition to any other premium rate reductions authorized under this title. Premium rate filings shall include the information and data required under section 38a-479qqq if the policy is subject to said section, and an actuarial memorandum that includes, but is not limited to, pricing assumptions and claims experience, and premium rates and loss ratios from the inception of the policy. Each premium rate filed on or after January 1, 2021, shall, if the insurer intends to account for rebates, as defined in section 38a-479ooo in the manner specified in section 38a-479rrr, account for such rebates in such manner, if the policy is subject to section 38a-479rrr. As used in this subdivision, “loss ratio” means the ratio of incurred claims to earned premiums by the number of years of policy duration for all combined durations.”
(P.A. 90-243, S. 97; P.A. 93-390, S. 7, 8; P.A. 96-51, S. 3; P.A. 05-20, S. 6; P.A. 08-181, S. 6; P.A. 11-19, S. 32; P.A. 14-235, S. 28; P.A. 15-118, S. 51; 15-247, S. 7; P.A. 18-41, S. 9; P.A. 25-94, S. 7.)
History: P.A. 93-390 added Subsec. (b) prohibiting the incorporation of factors for age, gender, previous claim or medical condition history, into the insurer's rate schedule, effective January 1, 1994; P.A. 96-51 added Subsec. (c) to permit optional life insurance riders; P.A. 05-20 made technical changes, amended Subsec. (a) re regulations and amended Subsec. (b) to reference “determinations to grant coverage” and plans “H” to “J”, inclusive, “issued prior to January 1, 2006,” re use of claim history and medical condition, effective July 1, 2005; P.A. 08-181 added Subsec. (d) directing commissioner to adopt regulations to establish minimum benefit standards for group specified disease policies, effective June 12, 2008; P.A. 11-19 amended Subsec. (b) to delete provisions re Medicare supplement plans “H” to “J”; P.A. 14-235 made technical changes in Subsec. (c); P.A. 15-118 made technical changes in Subsecs. (a) and (b); P.A. 15-247 amended Subsec. (a) by designating existing provisions re submission and approval of policy and certificate form as Subdiv. (1) and amending same by replacing provision re issuance of order with provisions re disapproval of form, and adding Subdiv. (2) re submission and approval of small employer rates and definition of “loss ratio”, and made technical changes, effective July 10, 2015; P.A. 18-41 amended Subsec. (a)(2) by adding provisions re inclusion of information and data required under Sec. 38a-479qqq and accounting for rebates in manner specified in Sec. 38a-479rrr, effective January 1, 2020; P.A. 25-94 amended Subsec. (a)(2) by adding provision re commissioner may reduce requested rate filing if commissioner determines that the average premium rate increase exceeded the health care cost growth benchmark for each of the two most recent plan years, effective January 1, 2027 (Revisor's note: In Subsec. (a), a reference to “subsection (a) of this section” which appeared in the engrossed bill was changed editorially by the Revisors to “of this subsection” for clarity).
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Sec. 38a-514b. *(See end of section for amended version of subdivision (4) of subsection (a) and effective date.) Coverage for autism spectrum disorder. (a) As used in this section:
(1) “Applied behavior analysis” means the design, implementation and evaluation of environmental modifications, using behavioral stimuli and consequences, including the use of direct observation, measurement and functional analysis of the relationship between environment and behavior, to produce socially significant improvement in human behavior.
(2) “Autism spectrum disorder services provider” means any person, entity or group that provides treatment for autism spectrum disorder pursuant to this section.
(3) “Autism spectrum disorder” means “autism spectrum disorder” as set forth in the most recent edition of the American Psychiatric Association's “Diagnostic and Statistical Manual of Mental Disorders”.
*(4) “Behavioral therapy” means any interactive behavioral therapies derived from evidence-based research and consistent with the services and interventions designated by the Commissioner of Social Services pursuant to subsection (e) of section 17a-215c, including, but not limited to, applied behavior analysis, cognitive behavioral therapy, or other therapies supported by empirical evidence of the effective treatment of individuals diagnosed with autism spectrum disorder, that are: (A) Provided to children less than twenty-one years of age; and (B) provided or supervised by (i) a licensed behavior analyst, (ii) a licensed physician, or (iii) a licensed psychologist. For the purposes of this subdivision, behavioral therapy is “supervised by” such licensed behavior analyst, licensed physician or licensed psychologist when such supervision entails at least one hour of face-to-face supervision of the autism spectrum disorder services provider by such licensed behavior analyst, licensed physician or licensed psychologist for each ten hours of behavioral therapy provided by the supervised provider.
(5) “Diagnosis” means the medically necessary assessment, evaluation or testing performed by a licensed physician, licensed psychologist or licensed clinical social worker to determine if an individual has autism spectrum disorder.
(b) Each 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 shall provide coverage for the diagnosis and treatment of autism spectrum disorder. For the purposes of this section and section 38a-513c, autism spectrum disorder shall be considered an illness.
(c) Such policy shall provide coverage for the following treatments, provided such treatments are (1) medically necessary, and (2) identified and ordered by a licensed physician, licensed psychologist or licensed clinical social worker for an insured who is diagnosed with autism spectrum disorder, in accordance with a treatment plan developed by a licensed behavior analyst, licensed physician, licensed psychologist or licensed clinical social worker, pursuant to a comprehensive evaluation or reevaluation of the insured:
(A) Behavioral therapy;
(B) Prescription drugs, to the extent prescription drugs are a covered benefit for other diseases and conditions under such policy, prescribed by a licensed physician, a licensed physician assistant or an advanced practice registered nurse for the treatment of symptoms and comorbidities of autism spectrum disorder;
(C) Direct psychiatric or consultative services provided by a licensed psychiatrist;
(D) Direct psychological or consultative services provided by a licensed psychologist;
(E) Physical therapy provided by a licensed physical therapist;
(F) Speech and language pathology services provided by a licensed speech and language pathologist; and
(G) Occupational therapy provided by a licensed occupational therapist.
(d) Such policy shall not impose (1) any limits on the number of visits an insured may make to an autism spectrum disorder services provider pursuant to a treatment plan on any basis other than a lack of medical necessity, or (2) a coinsurance, copayment, deductible or other out-of-pocket expense for such coverage that places a greater financial burden on an insured for access to the diagnosis and treatment of autism spectrum disorder than for the diagnosis and treatment of any other medical, surgical or physical health condition under such policy.
(e) (1) Except for treatments and services received by an insured in an inpatient setting, an insurer, health care center, hospital service corporation, medical service corporation or fraternal benefit society may review a treatment plan developed as set forth in subsection (c) of this section for such insured, in accordance with its utilization review requirements, not more than once every six months unless such insured's licensed physician, licensed psychologist or licensed clinical social worker agrees that a more frequent review is necessary or changes such insured's treatment plan.
(2) For the purposes of this section, the results of a diagnosis shall be valid for a period of not less than twelve months, unless such insured's licensed physician, licensed psychologist or licensed clinical social worker determines a shorter period is appropriate or changes the results of such insured's diagnosis.
(f) Coverage required under this section may be subject to the other general exclusions and limitations of the group health insurance policy, including, but not limited to, coordination of benefits, participating provider requirements, restrictions on services provided by family or household members and case management provisions, except that any utilization review shall be performed in accordance with subsection (e) of this section.
(g) (1) Nothing in this section shall be construed to limit or affect (A) any other covered benefits available to an insured under (i) such group health insurance policy, (ii) section 38a-514, or (iii) section 38a-516a, (B) any obligation to provide services to an individual under an individualized education program pursuant to section 10-76d, or (C) any obligation imposed on a public school by the Individual With Disabilities Education Act, 20 USC 1400 et seq., as amended from time to time.
(2) Nothing in this section shall be construed to require such group health insurance policy to provide reimbursement for special education and related services provided to an insured pursuant to section 10-76d, unless otherwise required by state or federal law.
(P.A. 08-132, S. 2; P.A. 09-115, S. 1; P.A. 11-4, S. 7; P.A. 12-145, S. 20; P.A. 13-84, S. 2; June Sp. Sess. P.A. 15-5, S. 347; May Sp. Sess. P.A. 16-3, S. 54; June Sp. Sess. P.A. 17-2, S. 198; P.A. 23-204, S. 281.)
*Note: On and after January 1, 2027, subdivision (4) of subsection (a) of this section, as amended by section 5 of public act 25-3 of the November special session, is to read as follows:
“(4) “Behavioral therapy” means any interactive behavioral therapies derived from evidence-based research and consistent with the services and interventions designated by the Commissioner of Social Services pursuant to subsection (e) of section 17a-215c, including, but not limited to, applied behavior analysis, cognitive behavioral therapy, or other therapies supported by empirical evidence of the effective treatment of individuals diagnosed with autism spectrum disorder, that are: (A) Provided to individuals under twenty-six years of age; and (B) provided or supervised by (i) a licensed behavior analyst, (ii) a licensed physician, or (iii) a licensed psychologist. For the purposes of this subdivision, behavioral therapy is “supervised by” such licensed behavior analyst, licensed physician or licensed psychologist when such supervision entails at least one hour of face-to-face supervision of the autism spectrum disorder services provider by such licensed behavior analyst, licensed physician or licensed psychologist for each ten hours of behavioral therapy provided by the supervised provider.”
(P.A. 08-132, S. 2; P.A. 09-115, S. 1; P.A. 11-4, S. 7; P.A. 12-145, S. 20; P.A. 13-84, S. 2; June Sp. Sess. P.A. 15-5, S. 347; May Sp. Sess. P.A. 16-3, S. 54; June Sp. Sess. P.A. 17-2, S. 198; P.A. 23-204, S. 281; Nov. Sp. Sess. P.A. 25-3, S. 5.)
History: P.A. 08-132 effective January 1, 2009; P.A. 09-115 designated existing provisions as Subsec. (b) and amended same by changing coverage from “for physical therapy, speech therapy and occupational therapy services” to “the diagnosis and treatment” of autism spectrum disorders, making conforming changes and adding provision re autism spectrum disorder to be considered an illness, and added Subsec. (a) re definitions, Subsec. (c) re types of treatment and Subsecs. (d) to (h) re limits on coverage, review and exceptions, effective January 1, 2010; P.A. 11-4 amended Subsec. (a)(3) by substituting “pervasive developmental disorder” for “pervasive developmental disorders” and by making a technical change, and amended Subsecs. (a) to (c) by substituting “autism spectrum disorder” for “autism spectrum disorders”, effective May 9, 2011; P.A. 12-145 made a technical change in Subsec. (a)(4), effective June 15, 2012; P.A. 13-84 amended Subsec. (b) by adding provision re coverage for insured diagnosed with autism spectrum disorder prior to release of the fifth edition of the American Psychiatric Association's “Diagnostic and Statistical Manual of Mental Disorders”, and added Subsec. (i) re same coverage provision, effective June 5, 2013; June Sp. Sess. P.A. 15-5 amended Subsec. (a) to replace “autism services provider” with “autism spectrum disorder services provider” in Subdiv. (2), redefine “autism spectrum disorder” in Subdiv. (3) and redefine “behavioral therapy” in Subdiv. (4), amended Subsec. (b) to delete coverage exception provisions, amended Subsec. (c) to add reference to behavior analyst certified by Behavior Analyst Certification Board, deleted former Subdiv. (d) re limit on coverage, redesignated existing Subsec. (e) as Subsec. (d) and amended same to insert “spectrum disorder”, redesignated existing Subsecs. (f) to (h) as Subsec. (e) to (g), deleted former Subsec. (i) re coverage maintenance, and made technical changes, effective January 1, 2016; May Sp. Sess. P.A. 16-3 amended Subsec. (a)(4) to replace “Commissioner of Developmental Services” with “Commissioner of Social Services”, effective July 1, 2016; June Sp. Sess. P.A. 17-2 amended Subsecs. (a)(4) and (c) to add references to licensed behavior analyst and delete references to certification of behavior analyst by Behavior Analyst Certification Board, effective July 1, 2018; P.A. 23-204 amended Subsec. (a)(4) by replacing reference to Sec. 17a-215c(l) with reference to Sec. 17a-215c(e), effective July 1, 2023; Nov. Sp. Sess. P.A. 25-3 amended Subsec. (a)(4)(A) by changing coverage age from under age 21 to under age 26, effective January 1, 2027.
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Sec. 38a-518w. Medically necessary wheelchair repairs, replacements. Coverage requirements. (a) As used in this section, (1) “complex rehabilitation technology wheelchair” has the same meaning as provided in section 42-337, and (2) “medically necessary” means a written determination by a policy holder's health care provider that repair or replacement of a complex rehabilitation technology wheelchair is necessary to preserve the health of such policy holder.
(b) Each group health insurance policy providing coverage of the types 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 and after January 1, 2025, shall not require a new prescription or prior authorization for the medically necessary repair or replacement of a complex rehabilitation technology wheelchair unless the original prescription is more than five years old.
(c) The Insurance Commissioner may adopt regulations, in accordance with chapter 54, to implement the provisions of this section.
(P.A. 24-58, S. 6; P.A. 25-132, S. 4.)
History: P.A. 24-58 effective July 1, 2024; P.A. 25-132 amended Subsec. (c) by replacing “shall” with “may” re commissioner's authority to adopt regulations, effective July 8, 2025.
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Sec. 38a-518y. Mandatory coverage for biomarker testing. (a) As used in this section:
(1) “Biomarker” means a characteristic, including, but not limited to, a gene mutation or protein expression that can be objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes or pharmacologic responses to a specific therapeutic intervention for a disease or condition.
(2) “Biomarker testing” means the analysis of a patient's tissue, blood or other biospecimen for the presence of a biomarker, including, but not limited to, tests for a single substance, tests for multiple substances and diseases or conditions. “Biomarker testing” does not include an evaluation of how a patient feels, functions or survives.
(3) “Clinical utility” means the test result provides information that is used in the formulation of a treatment or monitoring strategy that informs a patient's outcome and impacts the clinical decision.
(4) “Nationally recognized clinical practice guidelines” means evidence-based clinical practice guidelines informed by a systematic review of evidence and an assessment of the benefits and risks of alternative care options intended to optimize patient care developed by independent organizations or medical professional societies utilizing transparent methodologies and reporting structures and conflict-of-interest policies.
(b) 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 on or after January 1, 2026, shall provide coverage for biomarker testing for the purpose of diagnosis, treatment, appropriate management or ongoing monitoring of an insured's disease or condition, provided such biomarker testing provides clinical utility as demonstrated by medical and scientific evidence, including, but not limited to, one or more of the following: (1) Approval or clearance of such test by the federal Food and Drug Administration or recommendations on labels of drugs approved by the federal Food and Drug Administration to conduct such test, (2) national coverage determinations or local coverage determinations for Medicare Administrative Contractors by the Centers for Medicare and Medicaid Services, or (3) nationally recognized clinical practice guidelines. Such policy shall provide such coverage in a manner that limits disruptions in care, including, but not limited to, the need for multiple biopsies or biospecimen samples. Such policy may require that biomarker testing be performed at an in-network clinical laboratory, as defined in section 19a-490.
(c) Each entity providing such coverage shall establish a clear, readily accessible and convenient process through which an insured or an insured's health care provider may (1) request an exception to a coverage policy, or (2) dispute an adverse utilization review determination relating to such coverage. Each such entity shall post such process on the Internet web site maintained by such entity.
(d) If prior authorization is required before providing such coverage, each entity providing such coverage or each utilization review entity or other third party acting on behalf of such entity shall approve or deny such prior authorization and notify the insured, the insured's health care provider and any other entity requesting such prior authorization of such approval or denial (1) if the prior authorization is not urgent, as determined by the insured's health care provider, not later than seven days after receiving a prior authorization request, or (2) if the prior authorization is urgent, as determined by the insured's health care provider, not later than seventy-two hours after receiving a prior authorization request.
(P.A. 25-16, S. 5.)
History: P.A. 25-16 effective January 1, 2026.
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Sec. 38a-525a. Prior authorization prohibited for certain 9-1-1 emergency calls or transporting enrollee to a hospital by ambulance when medically necessary. Denial of payment to ambulance provider responding to 9-1-1 local prehospital emergency medical service system call prohibited on basis that enrollee did not obtain approval prior to calling such system or transporting such enrollee when medically necessary by ambulance to a hospital. (a) No group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469 and delivered, issued for delivery or renewed in this state, on or after January 1, 2025, shall direct or require an enrollee to obtain approval from the insurer or health care center prior to (1) calling a 9-1-1 local prehospital emergency medical service system whenever such enrollee is confronted with a life or limb threatening emergency, or (2) transporting such enrollee when medically necessary by ambulance to a hospital. For purposes of this section, a “life or limb threatening emergency” means any event which the enrollee believes threatens such enrollee's life or limb in such a manner that a need for immediate medical care is created to prevent death or serious impairment of health.
(b) No insurer or health care center subject to the provisions of subsection (a) of this section shall deny payment to any ambulance provider responding to a 9-1-1 local prehospital emergency medical service system call on the basis that the enrollee did not obtain approval from such insurer or health care center prior to calling such emergency medical service system or prior to transporting such enrollee when medically necessary by ambulance to a hospital.
(P.A. 96-67, S. 2; P.A. 24-19, S. 35; P.A. 25-97, S. 42.)
History: (Revisor's note: In codifying public act 96-67, an incorrect reference to “of subsection (a)” appearing before the reference to “section 38a-469” was deleted editorially by the Revisors); P.A. 24-19 designated existing provisions as Subsec. (a) and amended same by replacing “October 1, 1996” with “January 1, 2025”, inserting Subdiv. (1) designator and adding Subdiv. (2) prohibiting prior approval for transporting enrollee to hospital by ambulance when medically necessary and added Subsec. (b) prohibiting denial of payment to ambulance provider responding to 9-1-1 local prehospital emergency medical service system call on basis that enrollee did not obtain approval prior to calling such system or transporting such enrollee when medically necessary by ambulance to hospital, effective January 1, 2025; P.A. 25-97 amended Subsec. (a) by making a technical change.
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Sec. 38a-526b. Reimbursement for general anesthesia re time limit restrictions. (a) As used in this section:
(1) “General anesthesia” has the same meaning as provided in section 20-123a; and
(2) “Medically necessary” has the same meaning as provided in section 38a-482a.
(b) 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, 2026, shall, if such policy provides coverage for general anesthesia, (1) impose an arbitrary time limit on reimbursement for general anesthesia provided during any medically necessary procedure, or (2) deny, reduce, terminate or fail to provide such reimbursement, in whole or in part, for general anesthesia solely because the duration of care exceeded a predetermined time limit as determined by the insurer.
(P.A. 25-94, S. 9.)
History: P.A. 25-94 effective January 1, 2026.
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Sec. 38a-544. Prescription drug coverage. Mail order pharmacies. Step therapy use. (a) No insurance company, hospital service corporation, medical service corporation, health care center or other entity delivering, issuing for delivery, renewing, amending or continuing a group health insurance policy or contract that provides coverage for prescription drugs may:
(1) Require any person covered under such policy or contract to obtain prescription drugs from a mail order pharmacy as a condition of obtaining benefits for such drugs; or
(2) Require, if such insurance company, hospital service corporation, medical service corporation, health care center or other entity uses step therapy for such drugs, the use of step therapy (A) for any prescribed drug for longer than thirty days, (B) for a prescribed drug for cancer treatment for an insured who has been diagnosed with stage IV metastatic cancer, multiple sclerosis or rheumatoid arthritis, provided such prescribed drug is in compliance with approved federal Food and Drug Administration indications, or (C) for the treatment of schizophrenia, major depressive disorder or bipolar disorder, as defined in the most recent edition of the American Psychiatric Association's “Diagnostic and Statistical Manual of Mental Disorders”.
(3) At the expiration of the time period specified in subparagraph (A) of subdivision (2) of this subsection or for a prescribed drug described in subparagraph (B) or (C) of subdivision (2) of this subsection, an insured's treating health care provider may deem such step therapy drug regimen clinically ineffective for the insured, at which time the insurance company, hospital service corporation, medical service corporation, health care center or other entity shall authorize dispensation of and coverage for the drug prescribed by the insured's treating health care provider, provided such drug is a covered drug under such policy or contract. If such provider does not deem such step therapy drug regimen clinically ineffective or has not requested an override pursuant to subdivision (1) of subsection (b) of this section, such drug regimen may be continued. For purposes of this section, “step therapy” means a protocol or program that establishes the specific sequence in which prescription drugs for a specified medical condition are to be prescribed.
(b) (1) Notwithstanding the thirty-day period set forth in subparagraph (A) of subdivision (2) of subsection (a) of this section, each insurance company, hospital service corporation, medical service corporation, health care center or other entity that uses step therapy for such prescription drugs shall establish and disclose to its health care providers a process by which an insured's treating health care provider may request at any time an override of the use of any step therapy drug regimen. Any such override process shall be convenient to use by health care providers and an override request shall be expeditiously granted when an insured's treating health care provider demonstrates that the drug regimen required under step therapy (A) has been ineffective in the past for treatment of the insured's medical condition, (B) is expected to be ineffective based on the known relevant physical or mental characteristics of the insured and the known characteristics of the drug regimen, (C) will cause or will likely cause an adverse reaction by or physical harm to the insured, or (D) is not in the best interest of the insured, based on medical necessity.
(2) Upon the granting of an override request, the insurance company, hospital service corporation, medical service corporation, health care center or other entity shall authorize dispensation of and coverage for the drug prescribed by the insured's treating health care provider, provided such drug is a covered drug under such policy or contract.
(c) Nothing in this section shall (1) preclude an insured or an insured's treating health care provider from requesting a review under sections 38a-591c to 38a-591g, inclusive, or (2) affect the provisions of section 38a-518i.
(P.A. 89-374; P.A. 14-118, S. 2; P.A. 17-228, S. 2; P.A. 23-204, S. 226; P.A. 25-94, S. 5.)
History: P.A. 14-118 amended Subsec. (a) to designate existing provision re mail order pharmacy as Subdiv. (1) and add Subdiv. (2) re step therapy, deleted former Subsec. (b) re application of section, added new Subsec. (b) re step therapy override, added Subsec. (c) re effect of section on Secs. 38a-591c to 38a-591g and 38a-518i, and made technical and conforming changes, effective January 1, 2015; P.A. 17-228 amended Subsec. (a) to designate existing provisions re prescribed drug for longer than 60 days as Subpara. (A), and add Subpara. (B) re prescribed drug for cancer treatment in Subdiv. (2), designate existing provisions re deeming step therapy drug regimen clinically ineffective as Subdiv. (3) and amended same to add reference to Subdiv. (2), and make technical changes, effective January 1, 2018; P.A. 23-204 amended Subsec. (a) by substituting 30 days for 60 days in Subdiv. (2)(A), adding Subdiv. (2)(C) re step therapy prescription drug prohibition for treatment of schizophrenia, major depressive disorder and bipolar disorder from January 1, 2024, to January 1, 2027, and made technical and conforming changes, effective January 1, 2024; P.A. 25-94 amended Subsec. (a)(2)(B) re step therapy prescription drug prohibition for treatment of multiple sclerosis and rheumatoid arthritis, amended Subsec. (a)(2)(C) by deleting “for the period commencing January 1, 2024, and ending January 1, 2027, inclusive,”, and amended Subsec. (b)(1) by substituting 30 days for 60 days and making a technical change, effective January 1, 2026.
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Sec. 38a-556. (Formerly Sec. 38-376). Health Reinsurance Association. Board of directors. Powers and authority. Rates. Net loss assessment. Immunity from liability. (a) There is hereby created a nonprofit legal entity to be known as the Health Reinsurance Association. All insurers, health care centers and self-insurers doing business in the state, as a condition to their authority to transact the applicable kinds of health insurance defined in section 38a-551, shall be members of the association. The association shall perform its functions under a plan of operation established and approved under subsection (b) of this section, and shall exercise its powers through a board of directors established under this section.
(b) (1) The board of directors of the association shall be made up of nine individuals selected by participating members, subject to approval by the commissioner, two of whom shall be appointed by the commissioner on or before July 1, 1993, to represent health care centers. To select the initial board of directors, and to initially organize the association, the commissioner shall give notice to all members of the time and place of the organizational meeting. In determining voting rights at the organizational meeting, each member shall be entitled to vote in person or by proxy. The vote shall be a weighted vote based upon the net health insurance premium derived from this state in the previous calendar year. If the board of directors is not selected within sixty days after notice of the organizational meeting, the commissioner may appoint the initial board. In approving or selecting members of the board, the commissioner may consider, among other things, whether all members are fairly represented. Members of the board may be reimbursed from the moneys of the association for expenses incurred by them as members, but shall not otherwise be compensated by the association for their services.
(2) The board shall submit to the commissioner a plan of operation for the association necessary or suitable to assure the fair, reasonable and equitable administration of the association. The plan of operation shall become effective upon approval in writing by the commissioner. Such plan shall continue in force until modified by the commissioner or superseded by a plan submitted by the board and approved by the commissioner. The plan of operation shall: (A) Establish procedures for the handling and accounting of assets and moneys of the association; (B) establish regular times and places for meetings of the board of directors; (C) establish procedures for records to be kept of all financial transactions, and for the annual fiscal reporting to the commissioner; (D) establish procedures whereby selections for the board of directors shall be made and submitted to the commissioner; (E) establish procedures to amend, subject to the approval of the commissioner, the plan of operations; (F) establish procedures for the selection of an administrator and set forth the powers and duties of the administrator; (G) contain additional provisions necessary or proper for the execution of the powers and duties of the association; and (H) contain additional provisions necessary for the association to establish health insurance plans that qualify as acceptable coverage in accordance with the Pension Benefit Guaranty Corporation and other state or federal programs that may be established.
(c) The association shall have the general powers and authority granted under the laws of this state to carriers to transact the kinds of insurance defined under section 38a-551, and in addition thereto, the specific authority to: (1) Enter into contracts necessary or proper to carry out the provisions and purposes of this section and sections 38a-551 and 38a-557 to 38a-559, inclusive; (2) sue or be sued, including taking any legal actions necessary or proper for recovery of any assessments for, on behalf of, or against participating members; (3) take such legal action as necessary to avoid the payment of improper claims against the association or the coverage provided by or through the association; (4) establish, with respect to health insurance provided by or on behalf of the association, appropriate rates, scales of rates, rate classifications and rating adjustments, such rates not to be unreasonable in relation to the coverage provided and the operational expenses of the association; (5) administer any type of reinsurance program, for or on behalf of participating members; (6) pool risks among participating members; (7) issue policies of insurance required or permitted by this section and sections 38a-551 and 38a-557 to 38a-559, inclusive, in its own name or on behalf of participating members; (8) administer separate pools, separate accounts or other plans as deemed appropriate for separate members or groups of members; (9) operate and administer any combination of plans, pools, reinsurance arrangements or other mechanisms as deemed appropriate to best accomplish the fair and equitable operation of the association; (10) set limits on the amounts of reinsurance that may be ceded to the association by its members; (11) appoint from among participating members appropriate legal, actuarial and other committees as necessary to provide technical assistance in the operation of the association, policy and other contract design, and any other function within the authority of the association; (12) apply for and accept grants, gifts and bequests of funds from other states, federal and interstate agencies and independent authorities, private firms, individuals and foundations for the purpose of carrying out its responsibilities. Any such funds received shall be deposited in the General Fund and shall be credited to a separate, nonlapsing account for the Health Reinsurance Association and may be used by the Health Reinsurance Association in the performance of its duties; and (13) perform such other duties and responsibilities as may be required by state or federal law or permitted by state or federal law and approved by the commissioner.
(d) Rates for coverage issued by or through the association shall not be excessive, inadequate or unfairly discriminatory. All rates shall be promulgated by the association through an actuarial committee consisting of five persons who are members of the American Academy of Actuaries, shall be filed with the commissioner and may be disapproved within sixty days after the filing thereof if excessive, inadequate or unfairly discriminatory.
(e) (1) Following the close of each fiscal year, the administrator shall determine the net premiums, reinsurance premiums less administrative expense allowance, the expense of administration pertaining to the reinsurance operations of the association and the incurred losses for the year. Any net loss shall be assessed to all participating members in proportion to their respective shares of the total health insurance premiums earned in this state during the calendar year, or with paid losses in the year, coinciding with or ending during the fiscal year of the association or on any other equitable basis as may be provided in the plan of operations. For self-insured members of the association, health insurance premiums earned shall be established by dividing the amount of paid health losses for the applicable period by eighty-five per cent. Net gains, if any, shall be held at interest to offset future losses or allocated to reduce future premiums.
(2) Any net loss to the association represented by the excess of its actual expenses of administering policies issued by the association over the applicable expense allowance shall be separately assessed to those participating members who do not elect to administer their plans. All assessments shall be on an equitable formula established by the board.
(3) The association shall conduct periodic audits to assure the general accuracy of the financial data submitted to the association and the association shall have an annual audit of its operations by an independent certified public accountant. The annual audit shall be filed with the commissioner for his review and the association shall be subject to the provisions of section 38a-14.
(f) All policy forms issued by or through the association shall conform in substance to prototype forms developed by the association, shall in all other respects conform to the requirements of this section and sections 38a-551 and 38a-557 to 38a-559, inclusive, and shall be approved by the commissioner. The commissioner may disapprove any such form if it contains a provision or provisions that are unfair or deceptive or that encourage misrepresentation of the policy.
(g) Unless otherwise permitted by the plan of operation, the association shall not issue, reissue or continue in force health care plan coverage with respect to any person who is already covered under an individual or group health care plan, or who is sixty-five years of age or older and eligible for Medicare or who is not a resident of this state.
(h) Benefits payable under a health care plan insured by or reinsured through the association shall be paid net of all other health insurance benefits paid or payable through any other source, and net of all health insurance coverages provided by or pursuant to any other state or federal law including Title XVIII of the Social Security Act, Medicare, but excluding Medicaid.
(i) There shall be no liability on the part of and no cause of action of any nature shall arise against any carrier or its agents or its employees, the Health Reinsurance Association or its agents or its employees or the residual market mechanism established under the provisions of section 38a-557 or its agents or its employees, or the commissioner or the commissioner's representatives for any action taken by them in the performance of their duties under this section and sections 38a-551 and 38a-557 to 38a-559, inclusive. This provision shall not apply to the obligations of a carrier, a self-insurer, the Health Reinsurance Association or the residual market mechanism for payment of benefits provided under a health care plan.
(P.A. 75-616, S. 6, 12; P.A. 82-159, S. 2; P.A. 86-106, S. 4; P.A. 90-134, S. 25, 28; P.A. 93-338, S. 3; June 18 Sp. Sess. P.A. 97-8, S. 69, 70, 88; June 30 Sp. Sess. P.A. 03-6, S. 68; P.A. 04-10, S. 10, 11; 04-257, S. 63; P.A. 10-5, S. 33; P.A. 12-145, S. 22; P.A. 15-247, S. 15; P.A. 24-138, S. 17; P.A. 25-69, S. 3; 25-110, S. 117.)
History: P.A. 82-159 amended Subsec. (c) exempting losses resulting from retroactive coverage under Sec. 38-262c from consideration in determining premium rates; P.A. 86-106 amended Subsec. (f) to provide that no coverage shall be provided any individual who is both eligible for Medicare and 65 years of age or older; P.A. 90-134 removed language in Subsec. (c) re groups of between 3 and 25 employees or members; Sec. 38-376 transferred to Sec. 38a-556 in 1991; P.A. 93-338 expanded the scope of the Health Reinsurance Association to include “health care centers”, increased membership of the board of directors of the Health Reinsurance Association from seven to nine, adding two representatives of health care centers and added new Subsec. (d)(4) excluding health care centers in assessing net losses for the fiscal year ending December 31, 1993, and the first quarter of the fiscal year ending December 31, 1994; June 18 Sp. Sess. P.A. 97-8 added Subsec. (a)(I) re provisions necessary for the association to qualify as an acceptable alternative mechanism and amended Subsec. (f) re termination of coverage for a HIPAA eligible individual, effective July 1, 1997; June 30 Sp. Sess. P.A. 03-6 made a technical change, added Subsec. (a)(2)(J) re inclusion of provisions necessary for association to qualify as acceptable coverage in accordance with the Pension Benefit Guaranty Corporation and Trade Adjustment Assistance programs of the Trade Act of 2002, added Subsec. (b)(12) re application for and acceptance of grants for carrying out responsibilities and amended Subsec. (f) to include termination of coverage to health care tax credit eligible individuals and add reference to the Trade Act of 2002, effective August 20, 2003; P.A. 04-10 added “as” in Subsec. (b)(3) and substituted “substance” for “substances” in Subsec. (e); P.A. 04-257 made technical changes in Subsec. (c), effective June 14, 2004; P.A. 10-5 made technical changes, effective May 5, 2010; P.A. 12-145 made a technical change, effective June 15, 2012; P.A. 15-247 designated introductory language re creation of Health Reinsurance Association as new Subsec. (a), redesignated existing Subsec. (a) as Subsec. (b) and amended same by deleting provisions re consistency of date for and approval of plan of operation, deleting “, in addition to requirements enumerated in sections 38a-505, 38a-546 and 38a-551 to 38a-559, inclusive:”, deleting former Subparas. (H) and (I) re advertisement procedures and qualification as acceptable alternative mechanism, respectively, redesignating existing Subpara. (J) as Subpara. (H), and replacing reference to Trade Adjustment Assistance programs and adoption of regulations with reference to other state or federal programs in Subdiv. (2), redesignated existing Subsec. (b) as Subsec. (c) and amended same by deleting reference to Secs. 38a-505 and 38a-546 in Subdivs. (1) and (7), deleting reference to indemnity or provision of service basis and adding reference to this section and Sec. 38a-556a in Subdiv. (7) and adding Subdiv. (13) re performance of other duties and responsibilities, deleted former Subsec. (c)(1) and (2) re requirements for member participation in association, redesignated existing Subsec. (c)(3) re rates for coverage issued through association as Subsec. (d) and amended same by deleting provisions re adjustment of and consideration for rates, redesignated existing Subsec. (d) as Subsec. (e) and amended same by deleting former Subdiv. (4) re exclusion of health care centers in assessing net losses, redesignated existing Subsec. (e) as Subsec. (f) and amended same by deleting reference to Secs. 38a-505 and 38a-546 and adding reference to this section and Sec. 38a-556a, redesignated existing Subsec. (f) as Subsec. (g) and amended same by deleting “comprehensive” and provision re termination of coverage provided to HIPAA or health care tax credit eligible individual, redesignated existing Subsec. (g) as Subsec. (h) and amended same by deleting “comprehensive”, redesignated existing Subsec. (h) as Subsec. (i) and amended same by deleting reference to Secs. 38a-505 and 38a-546 and “comprehensive” and adding reference to this section and Sec. 38a-556a, and made technical and conforming changes, effective July 10, 2015; P.A. 24-138 amended Subsecs. (c), (f) and (i) to replace reference to Sec. 38a-556a with reference to Sec. 38a-557, effective June 6, 2024; P.A. 25-69 made technical changes in Subsec. (b)(1), effective June 23, 2025; P.A. 25-110 amended Subsec. (c) to delete reference to General Fund and make a technical change, effective July 1, 2025.
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