2019 Connecticut General Statutes
Title 38a - Insurance
Chapter 700c - Health Insurance
Section 38a-478g - Managed care contract requirements. Plan description requirements.

(a) Each managed care contract delivered, issued for delivery, renewed, amended or continued in this state shall be in writing and a copy thereof furnished to the group contract holder or individual contract holder, as appropriate. Each such contract shall contain the following provisions: (1) Name and address of the managed care organization; (2) eligibility requirements; (3) a statement of copayments, deductibles or other out-of-pocket expenses the enrollee must pay; (4) a statement of the nature of the health care services, benefits or coverages to be furnished and the period during which they will be furnished and, if there are any services, benefits or coverages to be excepted, a detailed statement of such exceptions; (5) a statement of terms and conditions upon which the contract may be cancelled or otherwise terminated at the option of either party; (6) claims procedures; (7) enrollee grievance procedures; (8) continuation of coverage; (9) extension of benefits, if any; (10) subrogation, if any; (11) description of the service area, and out-of-area benefits and services, if any; (12) a statement of the amount the enrollee or others on his behalf must pay to the managed care organization and the manner in which such amount is payable; (13) a statement that the contract includes the endorsement thereon and attached papers, if any, and contains the entire contract; (14) a statement that no statement by the enrollee in his application for a contract shall void the contract or be used in any legal proceeding thereunder, unless such application or an exact copy thereof is included in or attached to such contract; and (15) a statement of the grace period for making any payment due under the contract, which shall not be less than ten days. The commissioner may waive the requirements of this subsection for any managed care organization subject to the provisions of section 38a-182.

(b) Each managed care organization shall provide every enrollee with a plan description. The plan description shall be in plain language as commonly used by the enrollees and consistent with chapter 699a. The plan description shall be made available to each enrollee and potential enrollee prior to the enrollee’s entering into the contract and during any open enrollment period. The plan description shall not contain provisions or statements that are inconsistent with the plan’s medical protocols. The plan description shall contain:

(1) A clear summary of the provisions set forth in subdivisions (1) to (12), inclusive, of subsection (a) of this section, subdivision (3) of subsection (a) of section 38a-478c and sections 38a-478j to 38a-478l, inclusive;

(2) A statement of the number of managed care organization’s utilization review determinations not to certify an admission, service, procedure or extension of stay, and the denials upheld and reversed on appeal within the managed care organization’s utilization review procedure;

(3) A description of emergency services, the appropriate use of emergency services, including the use of E 9-1-1 telephone systems, any cost sharing applicable to emergency services and the location of emergency departments and other settings in which participating physicians and hospitals provide emergency services and post stabilization care;

(4) Coverage of the plans, including exclusions of specific conditions, ailments or disorders;

(5) The use of drug formularies or any limits on the availability of prescription drugs and the procedure for obtaining information on the availability of specific drugs covered;

(6) The number, types and specialties and geographic distribution of direct health care providers;

(7) Participating and nonparticipating provider reimbursement procedure;

(8) Prior authorization and utilization review requirements and procedures, internal grievance procedures and internal and external complaint procedures;

(9) The state medical loss ratio and the federal medical loss ratio, as both terms are defined in section 38a-478l, as reported in the last Consumer Report Card on Health Insurance Carriers in Connecticut;

(10) The plan’s for-profit, nonprofit incorporation and ownership status;

(11) Telephone numbers for obtaining further information, including the procedure for enrollees to contact the organization concerning coverage and benefits, claims grievance and complaint procedures after normal business hours;

(12) How notification is provided to an enrollee when the plan is no longer contracting with an enrollee’s primary care provider;

(13) The procedures for obtaining referrals to specialists or for consulting a physician other than the primary care physician;

(14) The status of the National Committee for Quality Assurance accreditation;

(15) Enrollee satisfaction information; and

(16) Procedures for protecting the confidentially of medical records and other patient information.

(P.A. 97-99, S. 8; June 18 Sp. Sess. P.A. 97-8, S. 58, 88; P.A. 09-46, S. 4; P.A. 11-58, S. 52; P.A. 12-145, S. 10; P.A. 15-118, S. 47; 15-247, S. 9; P.A. 17-15, S. 46.)

History: June 18 Sp. Sess. P.A. 97-8 amended Subsec. (a)(4) by deleting requirement of conformance to federal Health Maintenance Organization Act and (a)(16) by deleting reference to filing and amended Subsec. (b)(5) by adding provision re procedure for obtaining information on the availability of specific drugs, effective July 1, 1997; P.A. 09-46 amended Subsec. (a) to make a technical change and amended Subsec. (b)(9) to replace provision re percentage of total premium revenue with definition of medical loss ratio in Sec. 38a-478l(b) and provision re report in last consumer report card; P.A. 11-58 amended Subsec. (b)(9) to add federal medical loss ratio to information contained in plan description and make conforming changes, effective January 1, 2012; P.A. 12-145 made a technical change in Subsec. (b)(3), effective June 15, 2012; P.A. 15-118 made a technical change in Subsec. (b)(14); P.A. 15-247 amended Subsec. (a) to delete former Subdiv. (9) re conversion and redesignate existing Subdivs. (10) to (16) as Subdivs. (9) to (15), effective July 10, 2015; P.A. 17-15 made a technical change in Subsec. (b)(8).