2019 Connecticut General Statutes
Title 38a - Insurance
Chapter 700c - Health Insurance
Section 38a-528 - Group long-term care policies. Disclosures. Spreading of premium rate increases of twenty per cent or more. Disclosure of premium rate increase.
(a)(1) As used in this section, “long-term care policy” means any group health insurance policy or certificate delivered or issued for delivery to any resident of this state on or after July 1, 1986, that is designed to provide, within the terms and conditions of the policy or certificate, benefits on an expense-incurred, indemnity or prepaid basis for necessary care or treatment of an injury, illness or loss of functional capacity provided by a certified or licensed health care provider in a setting other than an acute care hospital, for at least one year after a reasonable elimination period. A long-term care policy shall provide benefits for confinement in a nursing home or confinement in the insured’s own home or both. Any additional benefits provided shall be related to long-term treatment of an injury, illness or loss of functional capacity. “Long-term care policy” does not include any such policy or certificate that is offered primarily to provide basic Medicare supplement coverage, basic medical-surgical expense coverage, hospital confinement indemnity coverage, major medical expense coverage, disability income protection coverage, accident only coverage, specified accident coverage or limited benefit health coverage.
(2) (A) No insurance company, fraternal benefit society, hospital service corporation, medical service corporation or health care center delivering, issuing for delivery, renewing, continuing or amending any long-term care policy in this state may refuse to accept, or refuse to make reimbursement pursuant to, a claim for benefits submitted by or prepared with the assistance of a managed residential community, as defined in section 19a-693, in accordance with subdivision (7) of subsection (a) of section 19a-694, solely because such claim for benefits was submitted by or prepared with the assistance of a managed residential community.
(B) Each insurance company, fraternal benefit society, hospital service corporation, medical service corporation or health care center delivering, issuing for delivery, renewing, continuing or amending any long-term care policy in this state shall, upon receipt of a written authorization executed by the insured, (i) disclose information to a managed residential community for the purpose of determining such insured’s eligibility for an insurance benefit or payment, and (ii) provide a copy of the initial acceptance or declination of a claim for benefits to the managed residential community at the same time such acceptance or declination is made to the insured.
(b) (1) No insurance company, fraternal benefit society, hospital service corporation, medical service corporation or health care center may deliver or issue for delivery any long-term care policy or certificate that has a loss ratio of less than sixty-five per cent for any group long-term care policy. An issuer shall not use or change premium rates for a long-term care policy or certificate unless the rates have been filed with the Insurance Commissioner. Deviations in rates to reflect policyholder experience shall be permitted, provided each policy form shall meet the loss ratio requirement of this section. Any rate filings or rate revisions shall demonstrate that anticipated claims in relation to premiums when combined with actual experience to date can be expected to comply with the loss ratio requirement of this section. On an annual basis, an insurer shall submit to the Insurance Commissioner an actuarial certification of the insurer’s continuing compliance with the loss ratio requirement of this section. Any rate or rate revision may be disapproved if the commissioner determines that the loss ratio requirement will not be met over the lifetime of the policy form using reasonable assumptions.
(2) (A) Any insurance company, fraternal benefit society, hospital service corporation, medical service corporation or health care center that files a rate filing for an increase in premium rates for a long-term care policy that is for twenty per cent or more shall spread the increase over a period of not less than three years. Such company, society, corporation or center shall use a periodic rate increase that is actuarially equivalent to a single rate increase and a current interest rate for the period chosen.
(B) Prior to implementing a premium rate increase, each such company, society, corporation or center shall:
(i) Notify its certificate holders of such premium rate increase and make available to such certificate holders the additional choice of reducing the policy benefits to reduce the premium rate. Such notice shall include a description of such policy benefit reductions. The premium rates for any benefit reductions shall be based on the new premium rate schedule;
(ii) Provide certificate holders not less than thirty calendar days to elect a reduction in policy benefits; and
(iii) Include a statement in such notice that if a certificate holder fails to elect a reduction in policy benefits by the end of the notice period and has not cancelled the policy, the certificate holder will be deemed to have elected to retain the existing policy benefits.
(c) (1) No such company, society, corporation or center may deliver or issue for delivery any long-term care policy without providing, at the time of solicitation or application for purchase or sale of such coverage, full and fair written disclosure of the benefits and limitations of the policy. The provisions of this subsection shall not be applicable to noncontributory plans.
(2) (A) The applicant shall sign an acknowledgment at the time of application for such policy that the company, society, corporation or center has provided the written disclosure required under this subsection to the applicant. If the method of application does not allow for such signature at the time of application, the applicant shall sign such acknowledgment not later than at the time of delivery of such policy.
(B) The policyholder shall provide a copy of such disclosure to each eligible individual.
(3) (A) Except for a long-term care policy for which no applicable premium rate revision or rate schedule increases can be made or as otherwise provided in subdivision (4) of this subsection, such disclosure shall include:
(i) A statement that the policy may be subject to rate increases in the future;
(ii) An explanation of potential future premium rate revisions and the policyholder’s or certificate holder’s option in the event of a premium rate revision;
(iii) The premium rate or rate schedule applicable to the applicant that will be in effect until such company, society, corporation or center files a request with the Insurance Commissioner for a revision to such premium rate or rate schedule;
(iv) An explanation of how a premium rate or rate schedule revision will be applied that includes a description of when such rate or rate schedule revision will be effective; and
(v) Information regarding each premium rate increase, if any, over the past ten years on such policy form or similar policy forms for this state or any other state, that identifies, at a minimum, (I) the policy forms for which premium rates have been increased, (II) the calendar years when each such policy form was available for purchase, and (III) the amount or percentage of each increase. The percentage may be expressed as a percentage of the premium rate prior to the increase or as minimum and maximum percentages if the rate increase is variable by rating characteristics.
(B) The company, society, corporation or center may provide, in a fair manner, any additional explanatory information related to a premium rate or rate schedule revision.
(4) (A) Any such company, society, corporation or center may exclude from the disclosure required under subdivision (3) of this subsection premium rate increases that only apply to blocks of business or long-term care policies acquired from a nonaffiliated company, society, corporation or center and that occurred prior to the acquisition.
(B) If an acquiring company, society, corporation or center files a request for a premium rate increase on or before January 1, 2015, or the end of a twenty-four-month period after the acquisition, whichever is later, for a block of policy forms or long-term care policies acquired from a nonaffiliated company, society, corporation or center such acquiring company, society, corporation or center may exclude from the disclosure required under subdivision (3) of this subsection such premium rate increase, except that the nonaffiliated company, society, corporation or center selling such block of policy forms or long-term care policies shall include such premium rate increase in such disclosure.
(C) If an acquiring company, society, corporation or center under subparagraph (B) of this subdivision files a subsequent request, even within the twenty-four-month period specified in said subparagraph, for a premium rate increase on the same block of policy forms or long-term care policies set forth in said subparagraph, the acquiring company, society, corporation or center shall include in the disclosure required under subdivision (3) of this subsection such premium rate increase and any premium rate increase filed and approved pursuant to subparagraph (B) of this subdivision.
(d) The Insurance Commissioner shall adopt regulations, in accordance with chapter 54, that address (1) the insured’s right to information prior to his replacing an accident and sickness policy with a long-term care policy, (2) the insured’s right to return a long-term care policy to the insurer, within a specified period of time after delivery, for cancellation, and (3) the insured’s right to accept by the insured’s signature, and prior to it becoming effective, any rider or endorsement added to a long-term care policy after the issuance date of such policy, provided (A) any regulations adopted pursuant to subdivisions (1) and (2) of this subsection shall not be applicable to (i) any long-term care policy that is delivered or issued for delivery to one or more employers or labor organizations, or to a trust or to the trustees of a fund established by one or more employers or labor organizations, or a combination thereof or for members or former members or a combination thereof, of the labor organizations, or (ii) noncontributory plans, and (B) any regulations adopted pursuant to subdivision (3) of this subsection shall not be applicable to any group long-term care policy. The Insurance Commissioner shall adopt such additional regulations as the commissioner deems necessary in accordance with said chapter 54 to carry out the purpose of this section.
(e) The Insurance Commissioner may, upon written request by any such company, society, corporation or center, issue an order to modify or suspend a specific provision of this section or any regulation adopted pursuant thereto with respect to a specific long-term care policy upon a written finding that: (1) The modification or suspension would be in the best interest of the insureds; (2) the purposes to be achieved could not be effectively or efficiently achieved without such modification or suspension; and (3) (A) the modification or suspension is necessary to the development of an innovative and reasonable approach for insuring long-term care, (B) the policy is to be issued to residents of a life care or continuing care retirement community or other residential community for the elderly and the modification or suspension is reasonably related to the special needs or nature of such community, or (C) the modification or suspension is necessary to permit long-term care policies to be sold as part of, or in conjunction with, another insurance product. Whenever the commissioner decides not to issue such an order, the commissioner shall provide written notice of such decision to the requesting party in a timely manner.
(f) Upon written request by any such company, society, corporation or center, the Insurance Commissioner may issue an order to extend the preexisting condition exclusion period, as established by regulations adopted pursuant to this section, for purposes of specific age group categories in a specific long-term care policy form whenever he makes a written finding that such an extension is in the best interest to the public. Whenever the commissioner decides not to issue such an order, the commissioner shall provide written notice of such decision to the requesting party in a timely manner.
(g) The provisions of section 38a-19 shall be applicable to any such requesting party aggrieved by any order or decision of the commissioner made pursuant to subsections (e) and (f) of this section.
(P.A. 90-243, S. 112; P.A. 91-276, S. 2; P.A. 93-239, S. 5; P.A. 94-39, S. 6; P.A. 10-127, S. 3; P.A. 13-134, S. 20; P.A. 14-8, S. 2; 14-10, S. 2; 14-235, S. 29; P.A. 17-15, S. 67.)
History: P.A. 91-276 substituted 65% for 60% in Subsec. (b) re loss ratio for any individual long-term care policy; P.A. 93-239 added the provision requiring a long-term care policy to provide benefits in the insured’s own home or in both a nursing home and his own home; P.A. 94-39 amended Subsec. (b) by adding provision requiring that issuer not use or change premium rates for a long-term policy or certificate without the filing and approval of the insurance commissioner, that any filing or revision of premium rates must comply with the loss ratio requirement for any group long-term care policy or certificate, that insurer submit annual actuarial certification of its continuing compliance with the loss ratio requirements, authorized disapproval of rate or revision if the commissioner determines that the loss ratio requirement will not be met over the lifetime of the policy form and added references to “policies” and “certificates” for statutory consistency; P.A. 10-127 amended Subsec. (a) by designating existing provisions as Subdiv. (1) and adding Subdiv. (2) re claims for benefits submitted or prepared by and disclosure of information to managed residential communities, effective July 1, 2010; P.A. 13-134 made a technical change in Subsec. (b); P.A. 14-8 amended Subsec. (c) to designate existing provisions re disclosure of policy benefits and limitations as new Subdiv. (1) and amend same to add “written” re disclosure, delete former Subdiv. (1) re applicability of Subsec. to policies delivered to employers or labor organizations and delete former Subdiv. (2) designator, and to add new Subdiv. (2) and Subdivs. (3) and (4) re acknowledgment, written disclosure and exclusions from disclosure, effective January 1, 2015; P.A. 14-10 amended Subsec. (a)(1) to make technical changes and amended Subsec. (b) to designate existing provisions as Subdiv. (1) and make a technical change therein, and add Subdiv. (2) re requirement to spread premium rate increase of 20 per cent or more over 3 years and premium rate increase notice; P.A. 14-235 made technical changes; P.A. 17-15 amended Subsec. (a)(1) by replacing “shall not include” with “does not include” re long-term care policy, made technical changes in Subsec. (a)(2)(A), and replaced “health service corporation” with “hospital service corporation” in Subsec. (b)(2)(A).
