2013 Connecticut General Statutes
Title 38a - Insurance
Chapter 700c - Health Insurance
Section 38a-476 - Preexisting condition coverage.


CT Gen Stat § 38a-476 (2013) What's This?

(a)(1) For the purposes of this section, “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) short-term health insurance issued on a nonrenewable basis with a duration of six months or less, 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 Insurance 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.

(2) “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.

(3) “Preexisting conditions provision” means a policy provision which limits or excludes benefits relating to a condition based on the fact that the condition was present before the effective date of coverage, for which any medical advice, diagnosis, care or treatment was recommended or received before such effective date. Routine follow-up care to determine whether a breast cancer has reoccurred in a person who has been previously determined to be breast cancer free shall not be considered as medical advice, diagnosis, care or treatment for purposes of this section unless evidence of breast cancer is found during or as a result of such follow-up. Genetic information shall not be treated as a condition in the absence of a diagnosis of the condition related to such information. Pregnancy shall not be considered a preexisting condition.

(4) “Qualifying coverage” means (A) any group health insurance plan, insurance arrangement or self-insured plan, (B) Medicare or Medicaid, or (C) an individual health insurance plan that provides benefits which are actuarially equivalent to or exceeding the benefits provided under the small employer health care plan, as defined in subdivision (12) of section 38a-564, whether issued in this state or any other state.

(5) “Applicable waiting period” means the period of time imposed by the group policyholder or contractholder before an individual is eligible for participating in the group policy or contract.

(b) (1) No group health insurance plan or insurance arrangement shall impose a preexisting conditions provision that excludes coverage for (A) individuals eighteen years of age and younger, or (B) a period beyond twelve months following the insured’s effective date of coverage. Any preexisting conditions provision shall only relate to conditions, whether physical or mental, for which medical advice, diagnosis or care or treatment was recommended or received during the six months immediately preceding the effective date of coverage.

(2) No individual health insurance plan or insurance arrangement shall impose a preexisting conditions provision that excludes coverage for (A) individuals eighteen years of age and younger, or (B) a period beyond twelve months following the insured’s effective date of coverage. Any preexisting conditions provision shall only relate to conditions, whether physical or mental, for which medical advice, diagnosis or care or treatment was recommended or received during the twelve months immediately preceding the effective date of coverage.

(3) No insurance company, fraternal benefit society, hospital service corporation, medical service corporation or health care center shall refuse to issue an individual health insurance plan or insurance arrangement to individuals eighteen years of age and younger solely on the basis that an individual has a preexisting condition.

(c) All health insurance plans and insurance arrangements shall provide coverage, under the terms and conditions of their policies or contracts, for the preexisting conditions of any newly insured individual who was previously covered for such preexisting condition under the terms of the individual’s preceding qualifying coverage, provided the preceding coverage was continuous to a date less than one hundred twenty days prior to the effective date of the new coverage, exclusive of any applicable waiting period, except in the case of a newly insured group member whose previous coverage was terminated due to an involuntary loss of employment, the preceding coverage must have been continuous to a date not more than one hundred fifty days prior to the effective date of the new coverage, exclusive of any applicable waiting period, provided such newly insured group member or dependent applies for such succeeding coverage within thirty days of the member’s or dependent’s initial eligibility.

(d) With respect to a newly insured individual who was previously covered under qualifying coverage, but who was not covered under such qualifying coverage for a preexisting condition, as defined under the new health insurance plan or arrangement, such plan or arrangement shall credit the time such individual was previously covered by qualifying coverage to the exclusion period of the preexisting condition provision, provided the preceding coverage was continuous to a date less than one hundred twenty days prior to the effective date of the new coverage, exclusive of any applicable waiting period under such plan, except in the case of a newly insured group member whose preceding coverage was terminated due to an involuntary loss of employment, the preceding coverage must have been continuous to a date not more than one hundred fifty days prior to the effective date of the new coverage, exclusive of any applicable waiting period, provided such newly insured group member or dependent applies for such succeeding coverage within thirty days of the member’s or dependent’s initial eligibility.

(e) Each insurance company, fraternal benefit society, hospital service corporation, medical service corporation or health care center which issues in this state group health insurance subject to Section 2701 of the Public Health Service Act, as set forth in the Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191) (HIPAA), as amended from time to time, shall comply with the provisions of said section with respect to such group health insurance, except that the longer period of days specified in subsections (c) and (d) of this section shall apply to the extent excepted from preemption in Section 2723(B)(2)(iii) of said Public Health Service Act.

(f) The provisions of this section shall apply to every health insurance plan or insurance arrangement issued, renewed or continued in this state on or after October 1, 1993. For purposes of this section, the date a plan or arrangement is continued shall be the anniversary date of the issuance of the plan or arrangement. The provisions of subsection (e) of this section shall apply on and after the dates specified in Sections 2747 and 2792 of the Public Health Service Act as set forth in HIPAA.

(g) Notwithstanding the provisions of subsection (a) of this section, a short-term health insurance policy issued on a nonrenewable basis for six months or less which imposes a preexisting conditions provision shall be subject to the following conditions: (1) No such preexisting conditions provision shall exclude coverage beyond twelve months following the insured’s effective date of coverage; (2) such preexisting conditions provision may only relate to conditions, whether physical or mental, for which medical advice, diagnosis, care or treatment was recommended or received during the twenty-four months immediately preceding the effective date of coverage; and (3) any policy, application or sales brochure issued for such short-term health insurance policy that imposes such preexisting conditions provision shall disclose in a conspicuous manner in not less than fourteen-point bold face type the following statement:

“THIS POLICY EXCLUDES COVERAGE FOR CONDITIONS FOR WHICH MEDICAL ADVICE, DIAGNOSIS, CARE OR TREATMENT WAS RECOMMENDED OR RECEIVED DURING THE TWENTY-FOUR MONTHS IMMEDIATELY PRECEDING THE EFFECTIVE DATE OF COVERAGE.”

In the event an insurer or health care center issues two consecutive short-term health insurance policies on a nonrenewable basis for six months or less which imposes a preexisting conditions provision to the same individual, the insurer or health care center shall reduce the preexisting conditions exclusion period in the second policy by the period of time such individual was covered under the first policy. If the same insurer or health care center issues a third or subsequent such short-term health insurance policy to the same individual, such insurer or health care center shall reduce the preexisting conditions exclusion period in the third or subsequent policy by the cumulative time covered under the prior policies. Nothing in this section shall be construed to require such short-term health insurance policy to be issued on a guaranteed issue or guaranteed renewable basis.

(h) The commissioner may adopt regulations, in accordance with the provisions of chapter 54, to enforce the provisions of HIPAA and this section concerning preexisting conditions and portability.

(P.A. 93-345, S. 3; P.A. 96-87, S. 1–3; 96-177, S. 5; June 18 Sp. Sess. P.A. 97-8, S. 65, 88; P.A. 98-27, S. 14; P.A. 00-121; P.A. 02-24, S. 5; P.A. 07-113, S. 3; P.A. 08-110, S. 2; P.A. 11-58, S. 41.)

History: P.A. 96-87 amended Subsec. (a) and added Subsec. (f) to exempt “short-term” policies which provide the prescribed disclosures, effective May 8, 1996; P.A. 96-177 redefined “preexisting conditions provision” to specify that breast cancer check-ups are not medical advice, diagnosis, care or treatment unless evidence of breast cancer is found; June 18 Sp. Sess. P.A. 97-8 redefined “preexisting conditions provision” in Subsec. (a), amended Subsec. (b) to delete references to pregnancy, to substitute “whether physical or mental” for “manifesting themselves or” in Subdiv. (1) and to substitute “whether physical or mental, which manifest themselves” for “manifesting themselves” in Subdiv. (2), amended Subsecs. (c) and (d) to substitute “less than sixty-three days” for “not more than thirty days” and to substitute “sixty-three days” for “thirty days”, added new Subsec. (e) re compliance with the Public Health Service Act, designated former Subsecs. (e) and (f) as Subsecs. (f) and (g) respectively, amending new Subsec. (f) re application dates of Subsec. (e), and added new Subsec. (h) re regulations to enforce HIPAA, effective July 1, 1997; P.A. 98-27 amended Subsec. (d) to substitute “time such individual” for “time such person” and substituted “such individual’s initial eligibility” for “their initial eligibility”; P.A. 00-121 amended Subsecs. (c) and (d) by amending time periods from 63 to 120 days and 90 to 150 days, amending application deadline from 63 to 30 days, and making technical changes for purposes of gender neutrality; P.A. 02-24 substituted “their” for “its” in Subsec. (c); P.A. 07-113 amended Subsec. (b)(2) to delete reference to conditions “which manifest themselves”, amended Subsec. (g) to require a short-term health insurance policy which imposes preexisting conditions provision to be subject to conditions, including a requirement for disclosure of a statement re exclusion of coverage under the policy in a conspicuous manner, to provide for a reduction in preexisting conditions exclusion period in the second, third or subsequent policy if an insurer or health care center issues two, three or more consecutive short-term health insurance policies with preexisting conditions provision to the same individual, and to require that nothing in section be construed to require short-term health insurance policy to be issued on a guaranteed issue or guaranteed renewable basis, and amended Subsec. (h) to authorize commissioner to adopt regulations to enforce provisions of section; P.A. 08-110 changed “may” to “shall” and made technical changes in Subsec. (b), effective May 27, 2008; P.A. 11-58 amended Subsec. (b) to prohibit preexisting conditions provision that excludes coverage for individuals 18 years of age and younger in Subdivs. (1) and (2), and added Subdiv. (3) prohibiting issuance refusal of an individual health insurance plan or arrangement to such individuals solely on the basis of a preexisting condition, effective July 2, 2011.

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