Sec. 38a-554. (Formerly Sec. 38-374). Additional requirements and eligibility under group comprehensive health care plans. Continuation of benefits under group plans. Insurance Commissioner's auth
Sec. 38a-554. (Formerly Sec. 38-374). Additional requirements and eligibility
under group comprehensive health care plans. Continuation of benefits under
group plans. Insurance Commissioner's authority to coordinate benefits. A group
comprehensive health care plan shall contain the minimum standard benefits prescribed
in section 38a-553 and shall also conform in substance to the requirements of this section.
(a) The plan shall be one under which the individuals eligible to be covered include:
(1) Each eligible employee; (2) the spouse of each eligible employee, who shall be
considered a dependent for the purposes of this section; and (3) unmarried children who
are under twenty-six years of age.
(b) The plan shall provide the option to continue coverage under each of the following circumstances until the individual is eligible for other group insurance, except as
provided in subdivisions (3) and (4) of this subsection: (1) Notwithstanding any provision of this section, upon layoff, reduction of hours, leave of absence, or termination of
employment, other than as a result of death of the employee or as a result of such employee's "gross misconduct" as that term is used in 29 USC 1163(2), continuation of coverage
for such employee and such employee's covered dependents for the periods set forth for
such event under federal extension requirements established by the federal Consolidated
Omnibus Budget Reconciliation Act of 1985, P.L. 99-272, as amended from time to
time, except that if such reduction of hours, leave of absence or termination of employment results from an employee's eligibility to receive Social Security income, continuation of coverage for such employee and such employee's covered dependents until midnight of the day preceding such person's eligibility for benefits under Title XVIII of the
Social Security Act; (2) upon the death of the employee, continuation of coverage for
the covered dependents of such employee for the periods set forth for such event under
federal extension requirements established by the Consolidated Omnibus Budget Reconciliation Act of 1985, P.L. 99-272, as amended from time to time; (3) regardless of the
employee's or dependent's eligibility for other group insurance, during an employee's
absence due to illness or injury, continuation of coverage for such employee and such
employee's covered dependents during continuance of such illness or injury or for up
to twelve months from the beginning of such absence; (4) regardless of an individual's
eligibility for other group insurance, upon termination of the group plan, coverage for
covered individuals who were totally disabled on the date of termination shall be continued without premium payment during the continuance of such disability for a period of
twelve calendar months following the calendar month in which the plan was terminated,
provided claim is submitted for coverage within one year of the termination of the plan;
(5) the coverage of any covered individual shall terminate: (A) As to a child, the plan
shall provide the option for said child to continue coverage for the longer of the following
periods: (i) At the end of the month following the month in which the child: Marries;
ceases to be a resident of the state; becomes covered under a group health plan through
the dependent's own employment; or attains the age of twenty-six. The residency requirement shall not apply to dependent children under nineteen years of age or full-time
students attending an accredited institution of higher education. If on the date specified
for termination of coverage on a child, the child is unmarried and incapable of self-sustaining employment by reason of mental or physical handicap and chiefly dependent
upon the employee for support and maintenance, the coverage on such child shall continue while the plan remains in force and the child remains in such condition, provided
proof of such handicap is received by the carrier within thirty-one days of the date on
which the child's coverage would have terminated in the absence of such incapacity.
The carrier may require subsequent proof of the child's continued incapacity and dependency but not more often than once a year thereafter, or (ii) for the periods set forth
for such child under federal extension requirements established by the Consolidated
Omnibus Budget Reconciliation Act of 1985, P.L. 99-272, as amended from time to
time; (B) as to the employee's spouse, at the end of the month following the month in
which a divorce, court-ordered annulment or legal separation is obtained, whichever is
earlier, except that the plan shall provide the option for said spouse to continue coverage
for the periods set forth for such events under federal extension requirements established
by the Consolidated Omnibus Budget Reconciliation Act of 1985, P.L. 99-272, as
amended from time to time; and (C) as to the employee or dependent who is sixty-five
years of age or older, as of midnight of the day preceding such person's eligibility for
benefits under Title XVIII of the federal Social Security Act; (6) as to any other event
listed as a "qualifying event" in 29 USC 1163, as amended from time to time, continuation of coverage for such periods set forth for such event in 29 USC 1162, as amended
from time to time, provided such plan may require the individual whose coverage is to
be continued to pay up to the percentage of the applicable premium as specified for such
event in 29 USC 1162, as amended from time to time. Any continuation of coverage
required by this section except subdivision (4) or (6) of this subsection may be subject
to the requirement, on the part of the individual whose coverage is to be continued, that
such individual contribute that portion of the premium the individual would have been
required to contribute had the employee remained an active covered employee, except
that the individual may be required to pay up to one hundred two per cent of the entire
premium at the group rate if coverage is continued in accordance with subdivision (1),
(2) or (5) of this subsection. The employer shall not be legally obligated by sections
38a-505, 38a-546 and 38a-551 to 38a-559, inclusive, to pay such premium if not paid
timely by the employee.
(c) The commissioner shall adopt regulations, in accordance with chapter 54, concerning coordination of benefits between the plan and other health insurance plans. No
individual or group health insurance plan shall coordinate benefits or otherwise reduce
benefit payments because a person is covered by or receives benefits from a group
specified disease policy delivered, issued for delivery, renewed, amended or continued
in this state.
(d) The plan shall make available to Connecticut residents, in addition to any other
conversion privilege available, a conversion privilege under which coverage shall be
available immediately upon termination of coverage under the group plan. The terms
and benefits offered under the conversion benefits shall be at least equal to the terms
and benefits of an individual comprehensive health care plan.
(P.A. 75-616, S. 4, 12; P.A. 76-399, S. 1, 5; P.A. 86-106, S. 2; P.A. 87-274, S. 2; P.A. 97-268, S. 2; P.A. 02-55, S. 1;
P.A. 03-77, S. 1; P.A. 07-185, S. 17; June Sp. Sess. P.A. 07-2, S. 65, 69; P.A. 08-147, S. 9; 08-181, S. 7.)
History: P.A. 76-399 allowed continuation of coverage to the thirty-ninth week following date of eligibility loss, rather
than the ninetieth day following such date in Subsec. (b)(1) and (2); P.A. 86-106 amended Subsec. (b) to provide that if a
dependent child is suffering from any mental handicap, rather than only mental retardation, on the date his coverage would
otherwise be terminated, the coverage may be continued, and to limit the termination of coverage of those eligible for
Medicare to those persons who are 65 years of age or older; P.A. 87-274 amended Subsec. (b) to increase extension rights
upon the loss of employment from 39 to 78 weeks, and upon the death of the employee from 39 to 156 weeks; Sec. 38-374 transferred to Sec. 38a-554 in 1991; P.A. 97-268 deleted reference to low, middle and high option deductibles, amended
Subsec. (a)(2) to make spouse a dependent for purposes of section, amended Subsec. (b)(1) and (2) to add disqualification
based on an employee's gross misconduct and to delete references to eligibility for periods of weeks and replace with
references to federal COBRA, amended Subsec. (b)(5) to add choice for covered child by adding designators (i) and (ii)
and allowing child and spouse to opt to continue coverage for periods provided under federal COBRA, and added court-ordered re annulment, added new Subdiv. (6) re other qualifying events, amended Subdiv. (7) to add reference to Subdiv.
(6), to add reference to 102% of the entire premium and to add reference to Subdiv. (2) or (5) and made technical changes;
P.A. 02-55 amended Subsec. (b)(3) to add "regardless of the employee's or dependent's eligibility for other group insurance"
re an absence due to illness or injury, amended Subsec. (b)(4) to add "regardless of an individual's eligibility for other
group insurance" re coverage for totally disabled individuals upon termination of the group plan, and made technical
changes in Subsecs. (b) and (c); P.A. 03-77 amended Subsec. (b)(1) to add exception re continuation of coverage if reduction
of hours, leave of absence or termination of employment results from eligibility to receive Social Security income; P.A.
07-185 amended Subsecs. (a) and (b) by making a child eligible for coverage under a parent's group comprehensive health
care plan as long as the child remains unmarried and is under the age of 26 and residing in the state, effective July 1, 2007;
June Sp. Sess. P.A. 07-2 changed effective date of P.A. 07-185, S. 17 to January 1, 2009, effective June 26, 2007, and
made provisions allowing children to continue coverage until age 26 contingent upon children remaining state residents,
except for full-time attendance at an out-of-state accredited institution of higher education or residency with a custodial
parent pursuant to a child custody determination, effective January 1, 2009; P.A. 08-147 amended Subsec. (a) by deleting
state residency requirement and amended Subsec. (b) by making technical changes and revising conditions upon which
coverage of a child terminates by adding provision re coverage under a group health plan through a dependent child's own
employment, deleting custodial parent provision, and specifying that dependent children to age 19 are exempt from state
residency requirement, effective January 1, 2009; P.A. 08-181 amended Subsec. (c) by prohibiting coordination of benefits
or reduction in benefit payments because a person is covered by or receives benefits from a group specified disease policy
in this state, effective June 12, 2008.
See Sec. 38a-497 for similar provisions re individual policies.