2019 Connecticut General Statutes
Title 38a - Insurance
Chapter 698a - Health Care and Related Service Groups
Section 38a-175 - (Formerly Sec. 33-179a). Definitions.

As used in this section and sections 38a-176 to 38a-194, inclusive:

(1) “Healing arts” means the professions and occupations licensed under the provisions of chapters 370, 372, 373, 375, 378, 379, 379a, 380, 381, 383 and 400j.

(2) “Carrier” means a health care center, insurer, hospital service corporation, medical service corporation or other entity responsible for the payment of benefits or provision of services under a group contract.

(3) “Commissioner” means the Insurance Commissioner, except when explicitly stated otherwise.

(4) “Evidence of coverage” means a statement of essential features and services of the health care center coverage that is given to the subscriber by the health care center or by the group contract holder.

(5) “Federal Health Maintenance Organization Act” means Title XIII of the Public Health Service Act, 42 USC Subchapter XI, as amended from time to time, or any successor thereto relating to qualified health maintenance organizations.

(6) “Group contract” means a contract for health care services that by its terms limits eligibility to members of a specified group. The group contract may include coverage for dependents.

(7) “Group contract holder” means the person to which a group contract has been issued.

(8) “Health care” includes, but shall not be limited to, the following: (A) For a health care center that provides medical and surgical services other than or in addition to dental services, (i) medical, surgical and dental care provided through licensed practitioners, including any supporting and ancillary personnel, services and supplies; (ii) physical therapy service provided through licensed physical therapists upon the prescription of a physician; (iii) psychological examinations provided by registered psychologists; (iv) optometric service provided by licensed optometrists; (v) hospital service, both inpatient and outpatient; (vi) convalescent institution care and nursing home care; (vii) nursing service provided by a registered nurse or by a licensed practical nurse; (viii) home care service of all types required for the health of a person; (ix) rehabilitation service required or desirable for the health of a person; (x) preventive medical services of all and any types; (xi) furnishing necessary appliances, drugs, medicines and supplies; (xii) educational services for the health and well-being of a person; (xiii) ambulance service; and (xiv) any other care, service or treatment related to the prevention or treatment of disease, the correction of defects and the maintenance of the physical and mental well-being of human beings. Any diagnosis and treatment of diseases of human beings required for health care as defined in this section, if rendered, shall be under the supervision and control of the providers; and (B) for a health care center that provides only dental services, dental care provided through licensed practitioners, including any supporting and ancillary personnel, services and supplies.

(9) “Health care center” means (A) any organization governed by sections 38a-175 to 38a-194, inclusive, and licensed or authorized by the commissioner pursuant to section 38a-41 or 38a-41a, for the purpose of carrying out the activities and purposes set forth in subsection (b) of section 38a-176, at the expense of the health care center, including the providing of health care to members of the community, including subscribers to one or more plans under an agreement entitling such subscribers to health care in consideration of a basic advance or periodic charge and shall include a health maintenance organization, or (B) a line of business conducted by an organization that is formed pursuant to the laws of this state for the purposes of, but not limited to, carrying out the activities and purposes set forth in subsection (b) of section 38a-176.

(10) “Individual contract” means a contract for health care services issued to and covering an individual. The individual contract may include dependents of the subscriber.

(11) “Individual practice association” means a partnership, corporation, association or other legal entity that has entered into a services arrangement with health care professionals licensed in this state to provide services to enrollees of a health care center.

(12) “Insolvent” or “insolvency” means, with respect to an organization, that the organization has been declared insolvent and placed under an order of liquidation by a court of competent jurisdiction.

(13) “Net worth” means the excess of total admitted assets over total liabilities, but the liabilities shall not include fully subordinated debt, as that term is used in section 38a-193.

(14) “Member” or “enrollee” means an individual who is enrolled in a health care center.

(15) “Person” means an individual, corporation, limited liability company, partnership, association, trust or any other legal entity.

(16) “Uncovered expenditures” means the cost of health care services that are covered by a health care center, for which an enrollee would also be liable in the event of the health care center’s insolvency, and for which no alternative arrangements have been made that are acceptable to the commissioner. “Uncovered expenditures” does not include expenditures for services when a provider has agreed not to bill the enrollee even though the provider is not paid by the health care center or for services that are guaranteed, insured or assumed by a person other than the health care center.

(17) “Enrolled population” means a group of persons, defined as to probable age, sex and family composition, that receives health care from a health care center in consideration of a basic advance or periodic charge.

(18) “Participating provider” means a provider who, under an express or implied contract with the health care center or with its contractor or subcontractor, has agreed to provide health care services to enrollees with an expectation of receiving payment, other than copayment or deductible, directly or indirectly from the health care center.

(19) “Provider” means any licensed health care professional or facility, including individual practice associations.

(20) “Subscriber” means an individual whose employment or other status, except family dependency, is the basis for eligibility for enrollment in the health care center, or in the case of an individual contract, the person in whose name the contract is issued.

(1971, P.A. 445, S. 1; P.A. 82-415, S. 1, 18; P.A. 90-68, S. 1, 16; P.A. 95-79, S. 141, 189; P.A. 11-19, S. 20; P.A. 15-198, S. 7; P.A. 16-213, S. 3, 20; P.A. 17-198, S. 15.)

History: P.A. 82-415 substituted “practitioners” for “physicians or dentists” in definition of “health care”, expanded the definition of health care center to include a corporation organized for profit and a health maintenance organization and added definitions of “person”, “individual practice association”, “member”, “uncovered expenditures”, “enrolled population” and “provider”; P.A. 90-68 amended the definitions re “healing arts”, “health care”, “health care center”, “individual practice association”, “person”, “uncovered expenditures” and “enrolled population” and added definitions of “carrier”, “commissioner”, “evidence of coverage”, “federal health maintenance organization act”, “group contract”, “group contract holder”, “individual contract”, “insolvent or insolvency”, “net worth”, “participating provider” and “subscriber”; Sec. 33-179a transferred to Sec. 38a-175 in 1991; P.A. 95-79 redefined “person” to include a limited liability company, effective May 31, 1995; P.A. 11-19 made a technical change in Subdiv. (2); P.A. 15-198 amended Subdiv. (1) to add reference to Ch. 400j, effective June 30, 2015; P.A. 16-213 amended Subdiv. (8) by adding Subpara. designators (A) to (M), amended Subdiv. (9) by redefining “health care center” and made technical changes, effective July 1, 2016, and amended Subdiv. (1) by adding reference to chapter 379a, and amended Subdiv. (8) by designating existing provisions as Subpara. (A) and amending same by adding provision re application to health care center that provides medical and surgical services other than or in addition to dental services, adding Subpara. (B) re health care center that provides only dental services and making conforming changes, effective July 1, 2017; P.A. 17-198 redefined “health care center” in Subdiv. (9), effective July 1, 2017.