Sec. 38a-182. (Formerly Sec. 33-179j). Agreements with subscribers. Agreement requirements. Evidence of coverage.
Sec. 38a-182. (Formerly Sec. 33-179j). Agreements with subscribers.
Agreement requirements. Evidence of coverage. (a) An agreement issued by a health
care center governed by sections 38a-175 to 38a-192, inclusive, may be issued for health
care or the costs thereof to a subscriber, to a subscriber and spouse, to a subscriber
and family, to a subscriber and dependent or dependents related by blood, marriage or
adoption or to a subscriber and ward. Such agreement or evidence of coverage document
shall be in writing and a copy thereof furnished to the group contract holder or individual
contract holder, as appropriate.
(b) Each such agreement shall contain the following provisions: (1) Name and address of the health care center; (2) eligibility requirements; (3) a statement of copayments, deductibles or other out-of-pocket expenses payment payable by the subscriber;
(4) a statement of the nature of the health care services or benefits to be furnished and
the period during which they will be furnished, and, if there are any services or benefits
to be excepted, a detailed statement of such exceptions provided that such services or
benefits to be furnished conform at a minimum to the requirements of the Federal Health
Maintenance Organization Act; (5) a statement of terms and conditions upon which the
agreement may be cancelled or otherwise terminated at the option of either party; (6)
claims procedures; (7) enrollee grievance procedures; (8) continuation of coverage; (9)
conversion; (10) extension of benefits, if any; (11) subrogation, if any; (12) description
of the service area, out-of-area benefits and services, if any; (13) a statement of the
amount payable to the health care center by the subscriber and by others on his behalf
and the manner in which such amount is payable; (14) a statement that the agreement
includes the endorsement thereon and attached papers, if any, and contains the entire
agreement; (15) a statement that no statement by the subscriber in his application for
an agreement shall void the agreement or be used in any legal proceeding thereunder,
unless such application or an exact copy thereof is included in or attached to such
agreement; and (16) a statement of the period of grace which will be allowed the subscriber for making any payment due under the agreement, which period shall not be less
than ten days.
(c) Every subscriber shall receive an evidence of coverage from the group contract
holder or the health care center. The evidence of coverage shall not contain provisions
or statements which are unfair, inequitable, misleading, deceptive or which encourage
misrepresentation. The evidence of coverage shall contain a clear statement of the provisions set forth in subdivisions (1) to (12), inclusive, of subsection (b) of this section.
(1971, P.A. 445, S. 10; P.A. 82-415, S. 6, 18; P.A. 90-68, S. 6, 16.)
History: P.A. 82-415 provided that services or benefits furnished to subscribers must conform to federal law requirements in Subdiv. (b) and substituted "health care center" for "corporation"; P.A. 90-68 divided section into Subsecs., made
various technical corrections, outlined the provisions required for health care agreements and added Subsec. (c) re guidelines
for the subscriber's evidence of coverage; Sec. 33-179j transferred to Sec. 38a-182 in 1991.