Sec. 38a-493. (Formerly Sec. 38-174k). Mandatory coverage for home health care. Deductibles. Exception from deductible limits for medical savings accounts, Archer MSAs and health savings accounts.
Sec. 38a-493. (Formerly Sec. 38-174k). Mandatory coverage for home health
care. Deductibles. Exception from deductible limits for medical savings accounts,
Archer MSAs and health savings accounts. (a) Every individual health insurance
policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10),
(11) and (12) of section 38a-469 delivered, issued for delivery or renewed in this state
on or after October 1, 1975, shall provide coverage providing reimbursement for home
health care to residents in this state.
(b) For the purposes of this section, "hospital" means an institution which is primarily engaged in providing, by or under the supervision of physicians, to inpatients (1)
diagnostic, surgical and therapeutic services for medical diagnosis, treatment and care
of injured, disabled or sick persons, or (2) medical rehabilitation services for the rehabilitation of injured, disabled or sick persons, provided "hospital" shall not include a residential care home, nursing home, rest home or alcohol or drug treatment facility, as defined
in section 19a-490. For the purposes of this section and section 38a-494, "home health
care" means the continued care and treatment of a covered person who is under the care
of a physician but only if (A) continued hospitalization would otherwise have been
required if home health care was not provided, except in the case of a covered person
diagnosed by a physician as terminally ill with a prognosis of six months or less to live,
and (B) the plan covering the home health care is established and approved in writing
by such physician within seven days following termination of a hospital confinement
as a resident inpatient for the same or a related condition for which the covered person
was hospitalized, except that in the case of a covered person diagnosed by a physician
as terminally ill with a prognosis of six months or less to live, such plan may be so
established and approved at any time irrespective of whether such covered person was
so confined or, if such covered person was so confined, irrespective of such seven-day period, and (C) such home health care is commenced within seven days following
discharge, except in the case of a covered person diagnosed by a physician as terminally
ill with a prognosis of six months or less to live.
(c) Home health care shall be provided by a home health agency. The term "home
health agency" means an agency or organization which meets each of the following
requirements: (1) It is primarily engaged in and is federally certified as a home health
agency and duly licensed, if such licensing is required, by the appropriate licensing
authority, to provide nursing and other therapeutic services, (2) its policies are established by a professional group associated with such agency or organization, including
at least one physician and at least one registered nurse, to govern the services provided,
(3) it provides for full-time supervision of such services by a physician or by a registered
nurse, (4) it maintains a complete medical record on each patient, and (5) it has an
administrator.
(d) Home health care shall consist of, but shall not be limited to, the following: (1)
Part-time or intermittent nursing care by a registered nurse or by a licensed practical
nurse under the supervision of a registered nurse, if the services of a registered nurse
are not available; (2) part-time or intermittent home health aide services, consisting
primarily of patient care of a medical or therapeutic nature by other than a registered
or licensed practical nurse; (3) physical, occupational or speech therapy; (4) medical
supplies, drugs and medicines prescribed by a physician, advanced practice registered
nurse or physician assistant and laboratory services to the extent such charges would
have been covered under the policy or contract if the covered person had remained or
had been confined in the hospital; (5) medical social services, as hereinafter defined,
provided to or for the benefit of a covered person diagnosed by a physician as terminally
ill with a prognosis of six months or less to live. Medical social services are defined to
mean services rendered, under the direction of a physician by a qualified social worker
holding a master's degree from an accredited school of social work, including but not
limited to (A) assessment of the social, psychological and family problems related to
or arising out of such covered person's illness and treatment; (B) appropriate action and
utilization of community resources to assist in resolving such problems; (C) participation
in the development of the overall plan of treatment for such covered person.
(e) The policy may contain a limitation on the number of home health care visits
for which benefits are payable, but the number of such visits shall not be less than eighty
in any calendar year or in any continuous period of twelve months for each person
covered under a policy or contract, except in the case of a covered person diagnosed by
a physician as terminally ill with a prognosis of six months or less to live, the yearly
benefit for medical social services shall not exceed two hundred dollars. Each visit by
a representative of a home health agency shall be considered as one home health care
visit; four hours of home health aide service shall be considered as one home health
care visit.
(f) Home health care benefits may be subject to an annual deductible of not more
than fifty dollars for each person covered under a policy and may be subject to a coinsurance provision which provides for coverage of not less than seventy-five per cent of the
reasonable charges for such services. Such policy may also contain reasonable limitations and exclusions applicable to home health care coverage. A "high deductible health
plan", as defined in Section 220(c)(2) or Section 223(c)(2) of the Internal Revenue Code
of 1986, or any subsequent corresponding internal revenue code of the United States,
as from time to time amended, used to establish a "medical savings account" or "Archer
MSA" pursuant to Section 220 of said Internal Revenue Code or a "health savings
account" pursuant to Section 223 of said Internal Revenue Code shall not be subject to
the deductible limits set forth in this subsection.
(g) No policy, except any major medical expense policy as described in subsection
(j), shall be required to provide home health care coverage to persons eligible for
Medicare.
(h) No insurer, hospital service corporation or health care center shall be required
to provide benefits beyond the maximum amount limits contained in its policy.
(i) If a person is eligible for home health care coverage under more than one policy,
the home health care benefits shall only be provided by that policy which would have
provided the greatest benefits for hospitalization if the person had remained or had been
hospitalized.
(j) Every individual major medical expense policy delivered, issued for delivery or
renewed in this state on or after October 1, 1989, shall provide coverage in accordance
with the provisions of this section for home health care to residents in this state whose
benefits are no longer provided under Medicare or any applicable individual health
insurance policy.
(P.A. 75-623, S. 1; P.A. 78-76, S. 1-3, 5; P.A. 84-375, S. 1, 3; P.A. 89-284; P.A. 90-243, S. 83; P.A. 96-19, S. 6; P.A.
97-112, S. 2; P.A. 03-78, S. 1; P.A. 04-174, S. 6.)
History: P.A. 78-76 specified applicability or inapplicability of provisions with respect to persons diagnosed as terminally ill with six months or less to live in Subsecs. (b), (d) and (e) and added "or had been" in Subsec. (i) preceding
"hospitalized"; P.A. 84-375 amended Subsec. (g) to exclude major medical expense policies, as described in Subsec. (j),
from the exemption in the subsection and added Subsec. (j), requiring that each major medical policy delivered, issued or
renewed on or after October 1, 1984, provide coverage for home health care to residents who have exhausted their other
policy or contract benefits; P.A. 89-284 amended Subsec. (b) to include a definition of "hospital" and amended Subsec.
(j) to clarify that home health care shall be provided in accordance with this section under the major medical policies of
insureds whose benefits are no longer provided under Medicare; P.A. 90-243 substituted references to "health insurance
policies" for references to hospital and medical expense policies or contracts, added reference to health care centers and
specified applicability solely to individual policies (Revisor's note: The reference to "or contract" at the end of Subsec.
(h) was deleted editorially by the Revisors for conformity with the changes made by P.A. 90-243); Sec. 38-174k transferred
to Sec. 38a-493 in 1991; P.A. 96-19 expanded reference in Subsec. (d) to prescriptions by physicians to include advanced
practice registered nurses and physician assistants; P.A. 97-112 replaced "home for the aged" with "residential care home";
P.A. 03-78 amended Subsec. (f) to provide that a high deductible health plan shall not be subject to the deductible limits
set forth in said Subsec., effective July 1, 2003; P.A. 04-174 amended Subsec. (f) to add references to "Archer MSA",
"health savings account" and Section 223 of the Internal Revenue Code re "high deductible health plans", effective June
1, 2004.
See Sec. 38a-520 for similar provisions re group policies.