2019 Connecticut General Statutes
Title 38a - Insurance
Chapter 700c - Health Insurance
Section 38a-564 - Definitions.
As used in this section and sections 38a-566, 38a-567, 38a-569 and 38a-574:
(1) “Pool” means the Connecticut Small Employer Health Reinsurance Pool, established under section 38a-569.
(2) “Board” means the board of directors of the pool.
(3) “Employee” means an individual employed by an employer. “Employee” does not include (A) an individual and such individual’s spouse with respect to an incorporated or unincorporated trade or business that is wholly owned by such individual, by such individual’s spouse or by such individual and such individual’s spouse, or (B) a partner in a partnership and such partner’s spouse with respect to such partnership.
(4) (A) “Small employer” means (i) prior to January 1, 2016, an employer that employed an average of at least one but not more than fifty employees on business days during the preceding calendar year and employs at least one employee on the first day of the group health insurance plan year, and (ii) on and after January 1, 2016, an employer that employed an average of at least one but not more than one hundred employees on business days during the preceding calendar year and employs at least one employee on the first day of the group health insurance plan year, except the commissioner may postpone said January 1, 2016, date to be consistent with any such postponement made by the Secretary of the United States Department of Health and Human Services under the Patient Protection and Affordable Care Act, P.L. 111-148, as amended from time to time. “Small employer” does not include a sole proprietorship that employs only the sole proprietor or the spouse of such sole proprietor.
(B) (i) For purposes of subparagraph (A) of this subdivision, the number of employees shall be determined by adding (I) the number of full-time employees for each month who work a normal work week of thirty hours or more, and (II) the number of full-time equivalent employees, calculated for each month by dividing by one hundred twenty the aggregate number of hours worked for such month by employees who work a normal work week of less than thirty hours, and averaging such total for the calendar year.
(ii) If an employer was not in existence throughout the preceding calendar year, the number of employees shall be based on the average number of employees that such employer reasonably expects to employ in the current calendar year.
(C) All persons treated as a single employer under Section 414 of the Internal Revenue Code of 1986, or any subsequent corresponding internal revenue code of the United States, as amended from time to time, shall be considered a single employer for purposes of this subdivision.
(5) “Insurer” means any insurance company, hospital service corporation, medical service corporation or health care center, authorized to transact health insurance business in this state.
(6) “Insurance arrangement” means any multiple employer welfare arrangement, as defined in Section 3 of the Employee Retirement Income Security Act of 1974, as amended from time to time, except for any such arrangement that is fully insured within the meaning of Section 514(b)(6) of said act, as amended from time to time.
(7) “Health insurance plan” means any hospital and medical expense incurred policy, hospital or medical service plan contract and health care center subscriber contract. “Health insurance 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 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; (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.
(8) “Plan of operation” means the plan of operation of the pool, including articles, bylaws and operating rules, adopted by the board pursuant to section 38a-569.
(9) “Dependent” means the spouse or child of an eligible employee, subject to applicable terms of the health insurance plan covering such employee. “Dependent” includes any dependent who is covered under the small employer’s health insurance plan pursuant to workers’ compensation, continuation of benefits pursuant to section 38a-512a or other applicable laws.
(10) “Commissioner” means the Insurance Commissioner.
(11) “Member” means each insurer and insurance arrangement participating in the pool.
(12) “Small employer carrier” means any insurer or insurance arrangement that offers or maintains group health insurance plans covering eligible employees of one or more small employers.
(13) “Health care center” has the same meaning as provided in section 38a-175.
(14) “Case characteristics” means demographic or other objective characteristics of a small employer, including age and geographic location. “Case characteristics” does not include claims experience, health status or duration of coverage since issue.
(P.A. 90-134, S. 12, 28; P.A. 91-201, S. 4, 8; P.A. 92-125, S. 1, 5; P.A. 93-137, S. 1, 6; 93-239, S. 9; 93-345, S. 6; P.A. 94-214, S. 2, 4; P.A. 95-79, S. 144, 189; P.A. 96-271, S. 213, 254; P.A. 99-124, S. 1, 4; P.A. 00-114, S. 1, 2; 00-218, S. 1; P.A. 01-30, S. 2, 4; June 30 Sp. Sess. P.A. 03-3, S. 32; P.A. 04-163, S. 1; P.A. 05-238, S. 3; P.A. 07-185, S. 18, 19; P.A. 08-110, S. 3; P.A. 10-4, S. 1; 10-5, S. 34; 10-13, S. 4; P.A. 11-19, S. 14; 11-58, S. 46; P.A. 14-122, S. 52; P.A. 15-118, S. 22; 15-247, S. 17; P.A. 17-15, S. 72.)
History: P.A. 91-201 redefined “small employer” to account for Taft-Hartley trust plans, clarified the definition of “late enrollee” for purposes of enrolling in a small employer health plan, and redefined “small employer carrier” to include maintenance of insurance plans, amended the definition of “base premium rate” to address small employer carriers not issuing new coverage and added a definition of “case characteristic”; P.A. 92-125 amended Subdiv. (9) to add provision concerning involuntary termination or cancellation, Subdiv. (24) to change annualized wages from all employers to the adjusted gross income from the most recent federal tax return filed prior to the date of application and added Subdiv. (28) to define “actuarial certification”; P.A. 93-137 redefined “eligible employee” to conditionally include any employee who is not actively at work but is covered under an employer’s health insurance plan, redefined “small employer” to require that the employer has been in business for at least 3 consecutive months during the preceding 12 months and redefined “dependent” to include any dependent who is covered under an employer health insurance plan, effective June 11, 1993; P.A. 93-239 corrected internal references in definition of “pool”; P.A. 93-345 added Subdiv. (7)(B) re policies of specified disease or limited health benefit and made technical changes; P.A. 94-214 amended the definition of “small employer” by increasing the number of eligible employees to qualify as a small employer from 25 to 50, effective July 1, 1994; P.A. 95-79 redefined “small employer” to include a limited liability company, effective May 31, 1995; P.A. 96-271 amended definition of “small employer” to replace reference to Sec. 33-374a with Sec. 33-840, effective January 1, 1997; P.A. 99-124 amended Subdiv. (4) to provide that “small employer” does not include a municipality procuring health insurance pursuant to Sec. 5-259, effective July 1, 1999; P.A. 00-114 amended definition of “small employer” in Subdiv. (4) to insert Subpara. (A) designator re municipalities and add new language as Subpara. (B) to exempt a private school procuring health insurance through an insurance arrangement or association of private schools, effective May 26, 2000; P.A. 00-218 redefined “small employer” in Subdiv. (4) to include persons self-employed for at least 3 consecutive months, and to state that “small employer includes a self-employed individual”; P.A. 01-30 added Subdiv. (4)(C) excluding certain nonprofit organizations from the definition of “small employer”, effective July 1, 2001; June 30 Sp. Sess. P.A. 03-3 added Subdiv. (4)(D) excluding an association for personal care assistants procuring health insurance pursuant to Sec. 5-259 from definition of “small employer”, effective August 20, 2003; P.A. 04-163 redefined “case characteristics” in Subdiv. (27) to include administrative cost savings, effective July 1, 2004; P.A. 05-238 amended Subdiv. (4) to redefine “small employer” by inserting Subpara. designators (A) and (B), redesignating existing Subparas. (A) to (D) as Subpara. (B)(i) to (iv) and adding Subpara. (B)(v) re community action agencies, effective July 8, 2005; P.A. 07-185 amended Subdiv. (19) to redefine “low-income eligible employee” as one whose annualized wages are less than 300% of the federal poverty level and amended Subdiv. (24) to redefine “low-income individual” as one whose adjusted gross income for the individual and spouse is less than 300% of the applicable federal poverty level, effective July 1, 2007; P.A. 08-110 made a technical change in Subdiv. (4)(A), effective May 27, 2008; P.A. 10-4 amended Subdiv. (3) to redefine “eligible employee” and amended Subdiv. (4) to redefine “small employer”, effective January 1, 2011; P.A. 10-5 made technical changes in Subdivs. (3) and (4)(A), effective May 5, 2010; P.A. 10-13 amended Subdiv. (3) to redefine “eligible employee”, amended Subdiv. (4) to redefine “small employer”, amended Subdiv. (13) to redefine “dependent” and made technical changes, effective May 5, 2010; P.A. 11-19 made technical changes; P.A. 11-58 redefined “preexisting conditions provision” in Subdiv. (17), effective July 2, 2011; P.A. 14-122 made a technical change in Subdiv. (6); P.A. 15-118 made technical changes in Subdiv. (5); P.A. 15-247 amended introductory language by replacing “12-201, 12-211, 12-212a and 38a-565 to 38a-572, inclusive” with “38a-566, 38a-567, 38a-569 and 38a-574”, deleted former Subdivs. (3), (4), (9) to (12), (17) to (25) and (28) re definitions of “eligible employee”, “small employer”, “late enrollee”, “department”, “special health care plan”, “small employer health care plan”, “preexisting conditions provision”, “base premium rate”, “low-income eligible employee”, “Medicare”, “Health Reinsurance Association”, “reimbursement rate”, “individual special health care plan”, “low-income individual”, “Medicare reimbursement rate” and “actuarial certification”, added new Subdivs. (3) and (4) re definition of “employee” and “small employer”, redesignated existing Subdiv. (13) as Subdiv. (9) and amended same by replacing “38a-554” with “38a-512a”, redesignated existing Subdivs. (14) to (16) and (26) as Subdivs. (10) to (13), respectively, redesignated existing Subdiv. (27) as Subdiv. (14) and amended same by redefining “case characteristics”, and made technical changes, effective July 10, 2015; P.A. 17-15 made a technical change in Subdiv. (7)(B).
