Sec. 38a-568. Coverage under small employer health care plans and arrangements. Approval by commissioner.
Sec. 38a-568. Coverage under small employer health care plans and arrangements. Approval by commissioner. (a)(1) Subject to approval by the commissioner,
the board shall establish the form and level of coverages to be made available by small
employer carriers in accordance with the provisions of subsection (b) of this section.
Such coverages, which shall be designated as small employer health care plans, shall
be limited to: (A) A basic hospital plan, (B) a basic surgical plan, (C) major medical
plans which can be written in conjunction with basic hospital plans or basic surgical
plans, (D) comprehensive plans, and (E) plans with benefit and cost-sharing levels which
are consistent with the basic method of operation and the benefit plans of health care
centers, including any restrictions imposed by federal law. The board shall submit such
plans to the commissioner for the commissioner's approval not later than ninety days
after the appointment of the board pursuant to section 38a-569. The board shall take
into consideration the levels of health insurance provided in Connecticut and such medical and economic factors as may be deemed appropriate and shall establish benefit levels,
deductibles, coinsurance factors, exclusions and limitations determined to be generally
reflective of health insurance provided to small employers. Such plans may include cost
containment features including, but not limited to: (i) Preferred provider provisions;
(ii) utilization review of health care services, including review of medical necessity of
hospital and physician services; (iii) case management benefit alternatives; and (iv)
other managed care provisions.
(2) After the commissioner's approval of small employer health care plans submitted by the board pursuant to subdivision (1) of this subsection, and in lieu of the procedure
established by section 38a-513, any small employer carrier may certify to the commissioner, in the form and manner prescribed by the commissioner, that the small employer
health care plans filed by the carrier are in substantial compliance with the provisions
in the corresponding approved board plan. Upon receipt by the department of such
certification, the carrier may use such certified plans until such time as the commissioner,
after notice and hearing, disapproves their continued use.
(b) Not later than ninety days after the commissioner's approval of small employer
health care plans submitted by the board, each small employer carrier, including, but
not limited to, each health care center, shall, as a condition of transacting such insurance
in this state, offer those small employer health care plans that correspond to the insurance
products being currently offered by the carrier to small employers. Each small employer
that elects to be covered under such plan and agrees to make the required premium
payments and to satisfy the other provisions of the plan shall be issued such a plan by
the small employer carrier.
(c) No health care center shall be required to offer coverage or accept applications
pursuant to subsection (b) of this section in the case of any of the following: (1) To a
group, where the group is not physically located in the health care center's approved
service area; (2) to an employee, where the employee does not work or reside within
the health care center's approved service area; (3) within an area, where the health care
center reasonably anticipates, and demonstrates to the satisfaction of the commissioner,
that it will not have the capacity within that area in its network of providers to deliver
services adequately to the members of such groups because of its obligations to existing
group contract holders and enrollees; (4) where the commissioner finds that acceptance
of an application or applications would place the health care center in an impaired financial condition; or (5) where the commissioner finds that compliance with subsection (b)
or (f) of this section would place the health care center in an impaired financial condition.
A health care center that refuses to offer coverage pursuant to subdivision (3) of this
subsection may not, for ninety days after such refusal, offer coverage in the applicable
area to new cases of employer groups with more than twenty-five eligible employees.
(d) A small employer carrier shall not be required to offer coverage or accept applications pursuant to subsection (b) of this section subject to the following conditions:
(1) The small employer carrier ceases to market health insurance or health benefit plans
to small employers and ceases to enroll small employers under existing health insurance
or health benefit plans; (2) the small employer carrier notifies the commissioner of its
decision to cease marketing to small employers and to cease enrolling small employers,
as provided in subdivision (1) of this subsection; and (3) the small employer carrier is
prohibited from reentering the small employer market for a period of five years from
the date of the notice required under subdivision (2) of this subsection.
(e) For groups containing only one member, a small employer carrier or health care
center offering coverage pursuant to this section may require proof that the individual
has been self-employed for three consecutive months.
(f) Each small employer carrier, including, but not limited to, a health care center,
shall offer each health care plan that the carrier makes available to small employers,
except association group plans, to all small employers, including, but not limited to,
groups containing only one member.
(P.A. 90-134, S. 19, 28; P.A. 91-201, S. 7, 8; P.A. 93-137, S. 4, 6; 93-239, S. 7; P.A. 00-218, S. 2; P.A. 01-174, S. 3, 4.)
History: P.A. 91-201 added Subsec. (d) setting conditions under which small employer carriers can stop offering small
employer coverage; P.A. 93-137 made technical changes for statutory accuracy, effective June 11, 1993; P.A. 93-239
corrected an internal reference in Subsec. (a)(2); P.A. 00-218 amended Subsecs. (a) and (b) to substitute "the commissioner's" for "his", "not later than" for "within", "including" for "such as" and "that" for "which", deleted Subsec. (c)(5)
exception allowing health care centers to refuse to offer coverage to groups of fewer than three eligible employees, and
added new Subsec. (e) re proof of self-employment for groups containing only one member; P.A. 01-174 amended Subsec.
(b) to add "including, but not limited to, each health care center" re small employer carriers, and substituted "each" for
"every", and added Subsec. (c)(5) re commissioner's finding re compliance with Subsec. (b) or (f) and added Subsec. (f)
re offer of health care plans, except association group plans, to all small employers.