Sec. 38a-478g. Managed care contract requirements. Plan description requirements.
Sec. 38a-478g. Managed care contract requirements. Plan description requirements. (a) Each managed care contract delivered, issued for delivery, renewed,
amended or continued in this state on or after October 1, 1997, shall be in writing and
a copy thereof furnished to the group contract holder or individual contract holder, as
appropriate. Each such contract shall contain the following provisions: (1) Name and
address of the managed care organization; (2) eligibility requirements; (3) a statement
of copayments, deductibles or other out-of-pocket expenses the enrollee must pay; (4)
a statement of the nature of the health care services, benefits or coverages to be furnished
and the period during which they will be furnished and, if there are any services, benefits
or coverages to be excepted, a detailed statement of such exceptions; (5) a statement of
terms and conditions upon which the contract 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, and out-of-area benefits and
services, if any; (13) a statement of the amount the enrollee or others on his behalf must
pay to the managed care organization and the manner in which such amount is payable;
(14) a statement that the contract includes the endorsement thereon and attached papers,
if any, and contains the entire contract; (15) a statement that no statement by the enrollee
in his application for a contract shall void the contract or be used in any legal proceeding
thereunder, unless such application or an exact copy thereof is included in or attached
to such contract; and (16) a statement of the grace period for making any payment due
under the contract, which shall not be less than ten days. The commissioner may waive
the requirements of this subsection for any managed care organization subject to the
provisions of section 38a-182.
(b) Each managed care organization shall provide every enrollee with a plan description. The plan description shall be in plain language as commonly used by the
enrollees and consistent with chapter 699a. The plan description shall be made available
to each enrollee and potential enrollee prior to the enrollee's entering into the contract
and during any open enrollment period. The plan description shall not contain provisions
or statements that are inconsistent with the plan's medical protocols. The plan description shall contain:
(1) A clear summary of the provisions set forth in subdivisions (1) to (12), inclusive,
of subsection (a) of this section, subdivision (3) of subsection (a) of section 38a-478c
and sections 38a-478j to 38a-478l, inclusive;
(2) A statement of the number of managed care organization's utilization review
determinations not to certify an admission, service, procedure or extension of stay, and
the denials upheld and reversed on appeal within the managed care organization's utilization review procedure;
(3) A description of emergency services, the appropriate use of emergency services,
including to the use of E 9-1-1 telephone systems, any cost sharing applicable to emergency services and the location of emergency departments and other settings in which
participating physicians and hospitals provide emergency services and post stabilization care;
(4) Coverage of the plans, including exclusions of specific conditions, ailments or
disorders;
(5) The use of drug formularies or any limits on the availability of prescription drugs
and the procedure for obtaining information on the availability of specific drugs covered;
(6) The number, types and specialties and geographic distribution of direct health
care providers;
(7) Participating and nonparticipating provider reimbursement procedure;
(8) Preauthorization and utilization review requirements and procedures, internal
grievance procedures and internal and external complaint procedures;
(9) The medical loss ratio, or percentage of total premium revenue spent on medical
care compared to administrative costs and plan marketing;
(10) The plan's for-profit, nonprofit incorporation and ownership status;
(11) Telephone numbers for obtaining further information, including the procedure
for enrollees to contact the organization concerning coverage and benefits, claims grievance and complaint procedures after normal business hours;
(12) How notification is provided to an enrollee when the plan is no longer contracting with an enrollee's primary care provider;
(13) The procedures for obtaining referrals to specialists or for consulting a physician other than the primary care physician;
(14) The status of the National Committee for Quality Assurance (NCQA) accreditation;
(15) Enrollee satisfaction information; and
(16) Procedures for protecting the confidentially of medical records and other patient information.
(P.A. 97-99, S. 8; June 18 Sp. Sess. P.A. 97-8, S. 58, 88.)
History: June 18 Sp. Sess. P.A. 97-8 amended Subsec. (a)(4) by deleting requirement of conformance to federal Health
Maintenance Organization Act and (a)(16) by deleting reference to filing and amended Subsec. (b)(5) by adding provision
re procedure for obtaining information on the availability of specific drugs, effective July 1, 1997.