Sec. 38a-564. Definitions.
Sec. 38a-564. Definitions. As used in sections 12-201, 12-211, 12-212a and 38a-564 to 38a-572, inclusive:
(1) "Pool" means the Connecticut Small Employer Health Reinsurance Pool, established under section 38a-569.
(2) "Board" means the board of directors of the pool.
(3) "Eligible employee" means an employee who works on a full-time basis, with
a normal work week of thirty or more hours and includes a sole proprietor, a partner of
a partnership or an independent contractor, provided such sole proprietor, partner or
contractor is included as an employee under a health care plan of a small employer but
does not include an employee who works on a part-time, temporary or substitute basis.
"Eligible employee" shall include any employee who is not actively at work but is
covered under the small employer's health insurance plan pursuant to workers' compensation, continuation of benefits pursuant to federal extension requirements established
by the Consolidated Omnibus Budget Reconciliation Act of 1985 (P.L. 99-272), as
amended, (COBRA) or other applicable laws. Such employees shall not be counted as
eligible employees for the purposes of subsection (4) of this section.
(4) (A) "Small employer" means any person, firm, corporation, limited liability
company, partnership or association actively engaged in business or self-employed for
at least three consecutive months who, on at least fifty per cent of its working days
during the preceding twelve months, employed no more than fifty eligible employees,
the majority of whom were employed within the state of Connecticut. "Small employer"
includes a self-employed individual. In determining the number of eligible employees,
companies which are affiliated companies, as defined in section 33-840, or which are
eligible to file a combined tax return for purposes of taxation under chapter 208 shall
be considered one employer. Eligible employees shall not include employees covered
through the employer by health insurance plans or insurance arrangements issued to or
in accordance with a trust established pursuant to collective bargaining subject to the
federal Labor Management Relations Act. Except as otherwise specifically provided,
provisions of sections 12-201, 12-211, 12-212a and 38a-564 to 38a-572, inclusive, that
apply to a small employer shall continue to apply until the plan anniversary following
the date the employer no longer meets the requirements of this definition.
(B) "Small employer" does not include (i) a municipality procuring health insurance
pursuant to section 5-259, (ii) a private school in this state procuring health insurance
through a health insurance plan or an insurance arrangement sponsored by an association
of such private schools, (iii) a nonprofit organization procuring health insurance pursuant to section 5-259, unless the Secretary of the Office of Policy and Management and
the State Comptroller make a request in writing to the Insurance Commissioner that
such nonprofit organization be deemed a small employer for the purposes of this chapter,
(iv) an association for personal care assistants procuring health insurance pursuant to
section 5-259, or (v) a community action agency procuring health insurance pursuant
to section 5-259.
(5) "Insurer" means any insurance company, hospital or medical service corporation, or health care center, authorized to transact health insurance business in this state.
(6) "Insurance arrangement" means any "multiple employer welfare arrangement",
as defined in Section 3 of the Employee Retirement Income Security Act of 1974
(ERISA), as amended, except for any such arrangement which is fully insured within
the meaning of Section 514(b)(6) of said act, as amended.
(7) "Health insurance plan" means any hospital and medical expense incurred policy, hospital or medical service plan contract and health care center subscriber contract
and does not include (A) accident only, credit, dental, vision, Medicare supplement,
long-term care or disability insurance, hospital indemnity coverage, coverage issued as
a supplement to liability insurance, insurance arising out of a workers' compensation
or similar law, automobile medical-payments insurance, or insurance under which beneficiaries are payable without regard to fault and which is statutorily required to be contained in any liability insurance policy or equivalent self-insurance, or (B) policies of
specified disease or limited benefit health insurance, provided that the carrier offering
such policies files on or before March first of each year a certification with the commissioner that contains the following: (i) A statement from the carrier certifying that such
policies are being offered and marketed as supplemental health insurance and not as a
substitute for hospital or medical expense insurance; (ii) a summary description of each
such policy including the average annual premium rates, or range of premium rates in
cases where premiums vary by age, gender or other factors, charged for such policies
in the state; and (iii) in the case of a policy that is described in this subparagraph and
that is offered for the first time in this state on or after October 1, 1993, the carrier files
with the commissioner the information and statement required in this subparagraph at
least thirty days prior to the date such policy is issued or delivered in this state.
(8) "Plan of operation" means the plan of operation of the pool, including articles,
bylaws and operating rules, adopted by the board pursuant to section 38a-569.
(9) "Late enrollee" means an eligible employee or dependent who requests enrollment in a small employer's health insurance plan following the initial enrollment period
provided under the terms of the first plan for which such employee or dependent was
eligible through such small employer, provided an eligible employee or dependent shall
not be considered a late enrollee if (A) the request for enrollment is made within thirty
days after termination of coverage provided under another group health insurance plan
and if the individual had not initially requested coverage under such plan solely because
he was covered under another group health insurance plan and coverage under that plan
has ceased due to termination of employment, death of a spouse, or divorce, or due to
that plan's involuntary termination or cancellation by its carrier for reasons other than
nonpayment of premium, or (B) the individual is employed by an employer who offers
multiple health insurance plans and the individual elects a different health insurance
plan during an open enrollment period, or (C) a court has ordered coverage be provided
for a spouse or minor child under a covered employee's plan and request for enrollment
is made within thirty days after issuance of such court order or (D) if the request for
enrollment is made within thirty days after the marriage of such employee or the birth
or adoption of the first child by such employee after the later of the commencement of
the employer's plan or the date the pool becomes operational, and satisfactory evidence
of such marriage, birth or adoption is provided to the small employer carrier.
(10) "Department" means the Insurance Department.
(11) "Special health care plan" means a health insurance plan for previously uninsured small employers, established by the board in accordance with section 38a-565 or
by the Health Reinsurance Association in accordance with section 38a-570.
(12) "Small employer health care plan" means a health insurance plan for small
employers, established by the board in accordance with section 38a-568.
(13) "Dependent" means the spouse or child of an eligible employee, subject to
applicable terms of the health insurance plan covering such employee. Dependent shall
also include any dependent that is covered under the small employer's health insurance
plan pursuant to workers' compensation, continuation of benefits pursuant to federal
extension requirements established by the Consolidated Omnibus Budget Reconciliation Act of 1985 (P.L. 99-272), as amended, (COBRA) or other applicable laws.
(14) "Commissioner" means the Insurance Commissioner.
(15) "Member" means each insurer and insurance arrangement participating in
the pool.
(16) "Small employer carrier" means any insurer or insurance arrangement which
offers or maintains group health insurance plans covering eligible employees of one or
more small employers.
(17) "Preexisting conditions provision" means a policy provision which excludes
coverage for charges or expenses incurred during a specified period following the insured's effective date of coverage as to a condition which, during a specified period
immediately preceding the effective date of coverage, had manifested itself in such a
manner as would cause an ordinary prudent person to seek diagnosis, care or treatment
or for which medical advice, diagnosis, care or treatment was recommended or received
as to that condition or as to a condition which is pregnancy existing on the effective
date of coverage.
(18) "Base premium rate" means, as to any health insurance plan or insurance arrangement covering one or more employees of a small employer, the lowest new business premium rate charged by the insurer or insurance arrangement for the same or
similar coverage which is equivalent in value under a plan or arrangement covering
any small employer with similar case characteristics, other than claim experience, as
determined by such insurer or insurance arrangement, except that as to any small employer carrier or insurance arrangement not issuing new health insurance plans or insurance arrangements to a small employer, "base premium rate" means the lowest rate
charged a small employer for the same or similar coverage which is equivalent in value,
under a plan or arrangement covering any small employer with similar case characteristics, other than claim experience, as determined by such insurer or insurance arrangement.
(19) "Low-income eligible employee" means an eligible employee of a small employer whose annualized wages from such small employer determined as of the effective
date of the special health care plan or as of any anniversary of such effective date as
certified to the insurer or insurance arrangement or the Health Reinsurance Association,
as the case may be, by such small employer is less than three hundred per cent of the
federal poverty level applicable to such person.
(20) "Medicare" means the Health Insurance for the Aged Act, Title XVIII of the
Social Security Amendments of 1965, as amended.
(21) "Health Reinsurance Association" means the entity established and maintained
in accordance with the provisions of sections 38a-505, 38a-546 and 38a-551 to 38a-559, inclusive.
(22) "Reimbursement rate" means, as to individuals covered under special health
care plans or an individual special health care plan, seventy-five per cent of the Medicare
reimbursement rate for benefits normally reimbursable under Medicare. For services
or supplies not reimbursed by Medicare, such reimbursement shall be seventy-five per
cent of the amount which would be payable under Medicare, if Medicare was responsible
for benefit payments under such plans for such services and supplies, as determined by
the board and approved by the commissioner.
(23) "Individual special health care plan" means a health insurance plan for individuals, issued by the Health Reinsurance Association in accordance with section 38a-571
or issued by an insurer in accordance with section 38a-565.
(24) "Low-income individual" means an individual whose adjusted gross income
(AGI) for the individual and spouse, from the most recent federal tax return filed prior
to the date of application for the individual special health care plan or prior to any
anniversary of the effective date of the plan, as certified by such individual, is less than
three hundred per cent of the applicable federal poverty level.
(25) "Medicare reimbursement rate" means the amount which would be payable
under Medicare for benefits normally reimbursed under Medicare.
(26) "Health care center" means health care center as defined in section 38a-175.
(27) "Case characteristics" means demographic or other objective characteristics
of a small employer, including age, sex, family composition, location, size of group,
administrative cost savings resulting from the administration of an association group
plan or a plan written pursuant to section 5-259 and industry classification, as determined
by a small employer carrier, that are considered by the small employer carrier in the
determination of premium rates for the small employer. Claim experience, health status,
and duration of coverage since issue are not case characteristics for the purpose of
sections 38a-564 to 38a-572, inclusive.
(28) "Actuarial certification" means a written statement by a member of the American Academy of Actuaries or other individual acceptable to the commissioner that a
small employer carrier is in compliance with the provisions of subdivisions (4), (6), (7)
and (9) of section 38a-567 and the regulations promulgated by the commissioner pursuant to subdivision (8) of section 38a-567, based upon the person's examination, including a review of the appropriate records and of the actuarial assumptions and methods
used by the small employer carrier in establishing premium rates for applicable health
benefit plans.
(P.A. 90-134, S. 12, 28; P.A. 91-201, S. 4, 8; P.A. 92-125, S. 1, 5; P.A. 93-137, S. 1, 6; 93-239, S. 9; 93-345, S. 6; P.A.
94-214, S. 2, 4; P.A. 95-79, S. 144, 189; P.A. 96-271, S. 213, 254; P.A. 99-124, S. 1, 4; P.A. 00-114, S. 1, 2; 00-218, S.
1; P.A. 01-30, S. 2, 4; June 30 Sp. Sess. P.A. 03-3, S. 32; P.A. 04-163, S. 1; P.A. 05-238, S. 3; P.A. 07-185, S. 18, 19; P.A.
08-110, S. 3.)
History: P.A. 91-201 redefined "small employer" to account for Taft-Hartley trust plans, clarified the definition of "late
enrollee" for purposes of enrolling in a small employer health plan, and redefined "small employer carrier" to include
maintenance of insurance plans, amended the definition of "base premium rate" to address small employer carriers not
issuing new coverage and added a definition of "case characteristic"; P.A. 92-125 amended Subdiv. (9) to add provision
concerning involuntary termination or cancellation, Subdiv. (24) to change annualized wages from all employers to the
adjusted gross income from the most recent federal tax return filed prior to the date of application and added Subdiv. (28)
to define "actuarial certification"; P.A. 93-137 redefined "eligible employee" to conditionally include any employee who
is not actively at work but is covered under an employer's health insurance plan, redefined "small employer" to require
that the employer has been in business for at least 3 consecutive months during the preceding 12 months and redefined
"dependent" to include any dependent who is covered under an employer health insurance plan, effective June 11, 1993;
P.A. 93-239 corrected internal references in definition of "pool"; P.A. 93-345 added Subdiv. (7)(B) re policies of specified
disease or limited health benefit and made technical changes; P.A. 94-214 amended the definition of "small employer" by
increasing the number of eligible employees to qualify as a small employer from 25 to 50, effective July 1, 1994; P.A. 95-79 redefined "small employer" to include a limited liability company, effective May 31, 1995; P.A. 96-271 amended
definition of "small employer" to replace reference to Sec. 33-374a with Sec. 33-840, effective January 1, 1997; P.A. 99-124 amended Subdiv. (4) to provide that "small employer" does not include a municipality procuring health insurance
pursuant to Sec. 5-259, effective July 1, 1999; P.A. 00-114 amended definition of "small employer" in Subdiv. (4) to insert
Subpara. (A) designator re municipalities and add new language as Subpara. (B) to exempt a private school procuring
health insurance through an insurance arrangement or association of private schools, effective May 26, 2000; P.A. 00-218
redefined "small employer" in Subdiv. (4) to include persons self-employed for at least 3 consecutive months, and to state
that "small employer includes a self-employed individual"; P.A. 01-30 added Subdiv. (4)(C) excluding certain nonprofit
organizations from the definition of "small employer", effective July 1, 2001; June 30 Sp. Sess. P.A. 03-3 aded Subdiv.
(4)(D) excluding an association for personal care assistants procuring health insurance pursuant to Sec. 5-259 from definition of "small employer", effective August 20, 2003; P.A. 04-163 redefined "case characteristics" in Subdiv. (27) to include
administrative cost savings, effective July 1, 2004; P.A. 05-238 amended Subdiv. (4) to redefine "small employer" by
inserting Subpara. designators (A) and (B), redesignating existing Subparas. (A) to (D) as Subpara. (B)(i) to (iv) and adding
Subpara. (B)(v) re community action agencies, effective July 8, 2005; P.A. 07-185 amended Subdiv. (19) to redefine "low-income eligible employee" as one whose annualized wages are less than 300% of the federal poverty level and amended
Subdiv. (24) to redefine "low-income individual" as one whose adjusted gross income for the individual and spouse is less
than 300% of the applicable federal poverty level, effective July 1, 2007; P.A. 08-110 made a technical change in Subdiv.
(4)(A), effective May 27, 2008.