2019 Connecticut General Statutes
Title 38a - Insurance
Chapter 700c - Health Insurance
Section 38a-551 - (Formerly Sec. 38-371). Definitions.
For the purposes of this section and sections 38a-552 and 38a-556 to 38a-559, inclusive, the following terms have the following meanings:
(1) “Health insurance” or “health care plan” means hospital and medical expenses incurred policies written on a direct basis, nonprofit service plan contracts, health care center contracts and self-insured or self-funded employee health benefit plans. “Health insurance” or “health care plan” does not include (A) 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: (i) The carrier offering such policies files on or before March first of each year a certification with the 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; and (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 policy in the state; and (ii) for each such policy that is offered for the first time in this state on or after July 1, 2005, the carrier files with the commissioner the information and statement required in subparagraph (B)(i) of this subdivision at least thirty days prior to the date such policy is issued or delivered in this state.
(2) “Carrier” means an insurer, health care center, hospital service corporation or medical service corporation or fraternal benefit society.
(3) “Insurer” means an insurance company licensed to transact accident and health insurance business in this state.
(4) “Health care center” has the same meaning as provided in section 38a-175.
(5) “Self-insurer” or “self-insured or self-funded employee health benefit plan” means an employer or an employee welfare benefit fund or plan that provides payment for or reimbursement of the whole or any part of the cost of covered hospital or medical expenses for covered individuals. “Self-insurer” or “self-insured or self-funded employee health benefit plan” does not include any such employee welfare benefit fund or plan established prior to April 1, 1976, by any organization that is exempt from federal income taxes under the provisions of Section 501 of the United States Internal Revenue Code and amendments thereto and legal interpretations thereof, except any such organization described in Subsection (c)(15) of said Section 501.
(6) “Commissioner” means the Insurance Commissioner.
(7) “Resident employer” means any person, partnership, association, trust, estate, limited liability company, corporation, whether foreign or domestic, or the legal representative, trustee in bankruptcy or receiver or trustee, thereof, or the legal representative of a deceased person, including the state of Connecticut and each municipality therein that has in its employ one or more individuals during any calendar year, commencing January 1, 1976. “Resident employer” refers only to an employer with a majority of employees employed within the state of Connecticut.
(8) “Resident” means an individual who maintains a residence in this state for a period of at least one hundred eighty days.
(9) “Special health care plan” means a health insurance plan issued by the Health Reinsurance Association established under section 38a-556 for low-income individuals.
(10) “Low-income individual” means an individual whose family income is less than three hundred per cent of the federal poverty level for the calendar year prior to the date of application for an individual special health care plan or the year prior to the anniversary of the effective date of such plan, as certified by such individual.
(11) “Reimbursement rate” means, with respect to an individual special health care plan, (A) seventy-five per cent of the reimbursement rate payable under Medicare for benefits normally reimbursable under Medicare, or (B) for services and supplies that are not reimbursed by Medicare, seventy-five per cent of the amount that would be payable under Medicare if Medicare was responsible for payment for such services or supplies, as estimated by the board of directors of the Health Reinsurance Association and approved by the commissioner.
(P.A. 75-616, S. 1, 12; P.A. 76-399, S. 2, 5; P.A. 77-614, S. 163, 610; P.A. 80-482, S. 331, 345, 348; P.A. 90-243, S. 154; P.A. 91-100, S. 1; P.A. 93-338, S. 1; P.A. 95-79, S. 143, 189; June 18 Sp. Sess. P.A. 97-8, S. 67, 72, 88; P.A. 99-102, S. 45; P.A. 01-174, S. 11; June 30 Sp. Sess. P.A. 03-6, S. 66; P.A. 05-270, S. 1; P.A. 14-122, S. 169, 170; 14-235, S. 30; P.A. 15-247, S. 13.)
History: P.A. 76-399 added Subdivs. (o) to (r) defining “totally disabled”, “deductible”, “disease or injury” and “complications of pregnancy”; P.A. 77-614 placed insurance commissioner within the department of business regulation and made insurance department a division within that department, effective January 1, 1979; P.A. 80-482 restored insurance commissioner and division to prior independent status and abolished the department of business regulation; P.A. 90-243 made technical changes for statutory consistency; Sec. 38-371 transferred to Sec. 38a-551 in 1991; P.A. 91-100 added Subdiv. (s) to define “resident”; P.A. 93-338 in Subdiv. (a) added references to “health care center contracts” in definition of “health insurance”, in Subdiv. (b) added reference to “health care center” in definition of “carrier”, inserted new Subdiv. (d) defining “health care center” and relettered the former Subdivs. (e) to (t), inclusive, accordingly; P.A. 95-79 redefined “resident employer” to include a limited liability company, effective May 31, 1995; June 18 Sp. Sess. P.A. 97-8 redefined “resident” in Subdiv. (t) to include HIPAA eligible individual who maintains a residence in this state, and added new Subdiv. (u) to define “HIPAA eligible individual”, effective July 1, 1997; P.A. 99-102 amended Subdiv. (g) by deleting an obsolete reference to osteopathy and making a technical change; P.A. 01-174 substituted reference to Sec. 38a-696 for Sec. 38a-697 in Subdiv. (a); June 30 Sp. Sess. P.A. 03-6 made a technical change in Subdivs. (d), (i), (j) and (k), amended Subdiv. (t) to include in definition of “resident” a health care tax credit eligible individual and make a technical change, and added Subdiv. (v) defining “health care tax credit eligible individual”, effective August 20, 2003; P.A. 05-270 redefined “health insurance” in Subdiv. (a), effective July 1, 2005; P.A. 14-122 made technical changes in Subdivs. (i) to (k) and (o); P.A. 14-235 made a technical change in Subdiv. (q); P.A. 15-247 amended introductory language to replace reference to Secs. 38a-552 to 38a-559 with reference to Secs. 38a-552 and 38a-556 to 38a-559, redesignated existing Subdivs. (a) to (f), (m) and (t) as Subdivs. (1) to (8), respectively, deleted former Subdivs. (g) to (l), (n) to (s), (u) and (v) re definitions of “physician”, “qualified psychologist”, “skilled nursing facility”, “hospital”, “home health agency”, “copayment”, “eligible employee”, “alcoholism treatment facility”, “totally disabled”, “deductible”, “disease or injury”, “complications of pregnancy”, “HIPAA eligible individual” and “health care tax credit eligible individual”, redefined “resident” in redesignated Subdiv. (8), added Subdivs. (9) to (11) re definitions of “special health care plan”, “low-income individual” and “reimbursement rate”, and made technical and conforming changes, effective July 10, 2015.
