Section 38a-481 - (Formerly Sec. 38-165). Filing of policy form, application, classification of risks and rates. Approval of rates. Prescription drug rebates. Medicare supplement policies: Age, gender, previous claim or medical history rating prohibited. Reduction of payments on basis of Medicare eligibility. Optional life insurance rider. Treatment of health insurance issued to association or certain other insurance arrangements. Special enrollment periods. Grandfathered and nongrandfathered plans(a) No individual health insurance policy shall be delivered or issued for delivery to any person in this state, nor shall any application, rider or endorsement be used in connection with such policy, until a copy of the form thereof and of the classification of risks and the premium rates have been filed with the commissioner. Rate filings shall include the information and data required under section 38a-479qqq if the policy is subject to said section, and an actuarial memorandum that includes, but is not limited to, pricing assumptions and claims experience, and premium rates and loss ratios from the inception of the policy. Each premium rate filed on or after January 1, 2021, shall, if the insurer intends to account for rebates, as defined in section 38a-479ooo in the manner specified in section 38a-479rrr, account for such rebates in such manner, if the policy is subject to section 38a-479rrr. The commissioner may adopt regulations, in accordance with the provisions of chapter 54, to establish a procedure for reviewing such policies. The commissioner shall disapprove the use of such form at any time if it does not comply with the requirements of law, or if it contains a provision or provisions that are unfair or deceptive or that encourage misrepresentation of the policy. The commissioner shall notify, in writing, the insurer that has filed any such form of the commissioner's disapproval, specifying the reasons for disapproval, and ordering that no such insurer shall deliver or issue for delivery to any person in this state a policy on or containing such form. The provisions of section 38a-19 shall apply to such orders. As used in this subsection, "loss ratio" means the ratio of incurred claims to earned premiums by the number of years of policy duration for all combined durations.(b) No rate filed under the provisions of subsection (a) of this section shall be effective until it has been approved by the commissioner in accordance with regulations adopted pursuant to this subsection. The commissioner shall adopt regulations, in accordance with the provisions of chapter 54, to prescribe standards to ensure that such rates shall not be excessive, inadequate or unfairly discriminatory. The commissioner may disapprove such rate if it fails to comply with such standards, except that no rate filed under the provisions of subsection (a) of this section for any Medicare supplement policy shall be effective unless approved in accordance with section 38a-474.(c) No insurance company, fraternal benefit society, hospital service corporation, medical service corporation, health care center or other entity that delivers or issues for delivery in this state any Medicare supplement policies or certificates shall incorporate in its rates or determinations to grant coverage for Medicare supplement insurance policies or certificates any factors or values based on the age, gender, previous claims history or the medical condition of any person covered by such policy or certificate.(d) No individual health insurance policy delivered, issued for delivery, renewed, amended or continued in this state shall include any provision that reduces payments on the basis that an individual is eligible for Medicare by reason of age, disability or end-stage renal disease, unless such individual enrolls in Medicare. If such individual enrolls in Medicare, any such reduction shall be only to the extent such coverage is provided by Medicare.(e) Nothing in this chapter shall preclude the issuance of an individual health insurance policy that includes an optional life insurance rider, provided the optional life insurance rider shall be filed with and approved by the Insurance Commissioner pursuant to section 38a-430. Any company offering such policies for sale in this state shall be licensed to sell life insurance in this state pursuant to the provisions of section 38a-41.(f) Health insurance issued to an association or other insurance arrangement that is not made up solely of employer groups shall be treated as individual health insurance.(g)(1) As used in this subsection, "Affordable Care Act" means the Patient Protection and Affordable Care Act, P.L. 111-148, as amended from time to time, and regulations adopted thereunder, and "grandfathered plan" has the same meaning as "grandfathered health plan" as provided in the Affordable Care Act.(2) Each individual health insurance policy subject to the Affordable Care Act shall (A) be offered on a guaranteed issue basis with respect to all eligible individuals or dependents, and (B) provide special enrollment periods to (i) all eligible individuals or dependents as set forth in 45 CFR 147.104, as amended from time to time, and (ii) all eligible pregnant individuals not more than thirty days after the commencement of the pregnancy, as certified by any licensed health care provider acting within the scope of such health care provider's practice. Coverage under subparagraph (B)(ii) of this subdivision shall be (I) effective on the first of the month in which the individual receives such certification, and (II) limited to eligible individuals who do not have, at a minimum, essential benefits as determined under the Affordable Care Act or the coverage requirements under chapter 700c. Nothing in this subdivision shall be construed to prohibit any person from enrolling in an individual health insurance policy offered or sold through the exchange or not offered or sold through the exchange.(3) With respect to grandfathered plans of a policy under subdivision (2) of this subsection, the premium rates charged or offered shall be established on the basis of a single pool of all grandfathered plans.(4) With respect to nongrandfathered plans of a policy under subdivision (2) of this subsection: (A) The premium rates charged or offered shall be established on the basis of a single pool of all nongrandfathered plans, adjusted to reflect one or more of the following classifications: (i) Age, in accordance with a uniform age rating curve established by the commissioner;(ii) Geographic area, as defined by the commissioner;(iii) Tobacco use, except that such rate may not vary by a ratio of greater than 1.5 to 1.0 and may only be applied with respect to individuals who may legally use tobacco under state and federal law. For purposes of this subparagraph, "tobacco use" means the use of tobacco products four or more times per week on average within a period not longer than the six months immediately preceding. "Tobacco use" does not include the religious or ceremonial use of tobacco;(B) Total premium rates for family coverage shall be determined by adding the premiums for each individual family member, except that with respect to family members under twenty-one years of age, the premiums for only the three oldest covered children shall be taken into account in determining the total premium rate for such family.(5) Premium rates for a grandfathered or nongrandfathered policy under subdivision (2) of this subsection may vary by (A) actuarially justified differences in plan design, and (B) actuarially justified amounts to reflect the policy's provider network and administrative expense differences that can be reasonably allocated to such policy.Conn. Gen. Stat. § 38a-481
(1949 Rev., S. 6177; 1951, S. 2835d; 1967, P.A. 437, S. 1; P.A. 78-280, S. 6, 127; P.A. 88-230, S. 1, 12; 88-326, S. 4; P.A. 90-243, S. 72; P.A. 91-311; P.A. 93-390, S. 5, 8; P.A. 96-51, S. 2; P.A. 03-119, S. 1; P.A. 05-20, S. 3; P.A. 09-123, S. 1; P.A. 10-5, S. 18; P.A. 11-19, S. 29; P.A. 12-145, S. 11; P.A. 13-149, S. 1; P.A. 14-235, S. 55; P.A. 15-118, S. 50; 15-247, S. 6; P.A. 18-41, S. 8; 18-43, S. 2.)
Amended by P.A. 18-0041, S. 8 of the Connecticut Acts of the 2018 Regular Session, eff. 1/1/2020.Amended by P.A. 18-0043, S. 2 of the Connecticut Acts of the 2018 Regular Session, eff. 1/1/2019.Amended by P.A. 15-0118, S. 50 of the Connecticut Acts of the 2015 Regular Session, eff. 10/1/2015.Amended by P.A. 15-0247, S. 6 of the Connecticut Acts of the 2015 Regular Session, eff. 7/10/2015.Amended by P.A. 14-0235, S. 55 of the Connecticut Acts of the 2014 Regular Session, eff. 10/1/2014. Annotation to former section 38-165: Cited. 186 Conn. 507.
See Sec. 38a-477a re notification by Insurance Commissioner of required benefits and policy forms. See Sec. 38a-504 re insurance policy or contract requirements covering surgical removal of tumors and treatment of leukemia.