Sec. 38a-495. (Formerly Sec. 38-174m). Medicare supplement policies. Coverage of home health aid services and mammography. Prescription drug riders.
Sec. 38a-495. (Formerly Sec. 38-174m). Medicare supplement policies. Coverage of home health aid services and mammography. Prescription drug riders. (a)
As used in this section, "Medicare" means the Health Insurance for the Aged Act, Title
XVIII of the Social Security Amendments of 1965, as amended (Title I, Part I of P.L.
89-97); "Medicare supplement policy" means any individual health insurance policy
delivered or issued for delivery to any resident of the state who is eligible for Medicare,
except any long-term care policy as defined in section 38a-501.
(b) No insurance company, fraternal benefit society, hospital service corporation,
medical service corporation or health care center may deliver or issue for delivery any
Medicare supplement policy which has an anticipated loss ratio of less than sixty-five
per cent for any individual Medicare supplement policy defined in Section 1882(g) of
Title XVIII of the Social Security Act, 42 USC 1395ss(g), as amended. No such company, society or corporation may deliver or issue for delivery any Medicare supplement
policy without providing, at the time of solicitation or application for the purchase or sale
of such coverage, full and fair disclosure of any coverage supplementing or duplicating
Medicare benefits.
(c) Each Medicare supplement policy shall provide coverage for home health aide
services for each individual covered under the policy when such services are not paid
for by Medicare, provided (1) such services are provided by a certified home health aide
employed by a home health care agency licensed pursuant to sections 19a-490 to 19a-503, inclusive, and (2) the individual's physician has certified, in writing, that such
services are medically necessary. The policy shall not be required to provide benefits
in excess of five hundred dollars per year for such services. No deductible or coinsurance
provisions may be applicable to such benefits. If two or more Medicare supplement
policies are issued to the same individual by the same insurer, such coverage for home
health aide services shall be included in only one such policy. Notwithstanding the
provisions of subsection (g) of this section, the provisions of this subsection shall apply
with respect to any Medicare supplement policy delivered, issued for delivery, continued
or renewed in this state on or after October 1, 1986.
(d) Whenever a Medicare supplement policy provides coverage for the cost of prescription drugs prescribed after the hospitalization of the insured, outpatient surgical
procedures performed on the insured in any licensed hospital shall constitute "hospitalization" for purposes of such prescription drug coverage in such policy.
(e) Notwithstanding the provisions of subsection (g) of this section, each Medicare
supplement policy delivered, issued for delivery, continued or renewed in this state on
or after October 1, 1988, shall provide benefits, to any woman covered under the policy,
for mammographic examinations every year, or more frequently if recommended by
the woman's physician, when such examinations are not paid for by Medicare.
(f) The Insurance Commissioner shall adopt such regulations as he deems necessary
in accordance with chapter 54 to carry out the purposes of this section.
(g) The provisions of this section shall apply with respect to any Medicare supplement policy delivered, issued for delivery, continued or renewed in this state on or after
October 1, 1987, and prior to the effective date of any regulations adopted pursuant to
section 38a-495a.
(P.A. 79-289, S. 1, 2; P.A. 81-97; P.A. 86-49, S. 1, 3; 86-152; P.A. 87-181; 87-502; P.A. 88-124, S. 2; P.A. 90-243, S.
85; P.A. 92-111, S. 2, 4.)
History: P.A. 81-97 amended Subsec. (b), providing that a loss ratio of 75% be required for a group medicare supplement
policy defined in the federal act; P.A. 86-49 excluded long-term care policies from the definition of "Medicare supplement
policy"; P.A. 86-152 inserted new Subsec. (c) requiring that Medicare supplement policies provide coverage for home
health aide services, relettering prior Subsecs. as necessary; P.A. 87-181 amended Subsec. (c) to make its provisions
applicable to any Medicare supplement policy delivered, issued for delivery, continued or renewed on or after October 1,
1986; P.A. 87-502 inserted new Subsec. (d) defining what constitutes "hospitalization" for purposes of prescription drug
coverage, relettering prior Subsecs. as necessary; P.A. 88-124 inserted new Subsec. (e) requiring that Medicare supplement
policies provide coverage for mammography, relettering prior Subsecs. as necessary; P.A. 90-243 added references to
health care centers, deleted provisions concerning group policies and substituted reference to health insurance policies for
reference to accident and sickness policies; Sec. 38-174m transferred to Sec. 38a-495 in 1991; P.A. 92-111 amended
Subsec. (g) to make the provisions of this section applicable to Medicare supplement policy regulations adopted pursuant
to Sec. 38a-495a.
See Secs. 38a-199 to 38a-209, inclusive, re hospital service corporations.
See Secs. 38a-214 to 38a-225, inclusive, re medical service corporations.
See Sec. 38a-495a re Medicare supplement policies and certificates.
See Sec. 38a-522 re group Medicare supplement policies and certificates.
See Secs. 38a-595 to 38a-626, inclusive, 38a-631 to 38a-640, inclusive, and 38a-800 re fraternal benefit societies.