Sec. 38a-513c. Group health insurance policy to contain definition of "medically necessary" or "medical necessity".
Sec. 38a-513c. Group health insurance policy to contain definition of "medically necessary" or "medical necessity". (a) No insurer, health care center, hospital and
medical service corporation or other entity delivering, issuing for delivery, renewing,
continuing or amending any group health insurance policy providing coverage of the
type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469
in this state on or after January 1, 2008, shall deliver or issue for delivery in this state
any such policy unless such policy contains a definition of "medically necessary" or
"medical necessity" as follows: "Medically necessary" or "medical necessity" means
health care services that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an
illness, injury, disease or its symptoms, and that are: (1) In accordance with generally
accepted standards of medical practice; (2) clinically appropriate, in terms of type, frequency, extent, site and duration and considered effective for the patient's illness, injury
or disease; and (3) not primarily for the convenience of the patient, physician or other
health care provider and not more costly than an alternative service or sequence of
services at least as likely to produce equivalent therapeutic or diagnostic results as to
the diagnosis or treatment of that patient's illness, injury or disease. For the purposes
of this subsection, "generally accepted standards of medical practice" means standards
that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community or otherwise consistent
with the standards set forth in policy issues involving clinical judgment.
(b) The provisions of subsection (a) of this section shall not apply to any insurer,
health care center, hospital and medical service corporation or other entity that has
entered into any national settlement agreement until the expiration of any such
agreement.
(P.A. 07-75, S. 2.)
History: P.A. 07-75 effective January 1, 2008.
See Sec. 38a-482a for similar provisions re individual policies.