Connecticut General Statutes 38a-472j – Restrictions applicable to cost-sharing for covered benefits. Regulations
(a) Notwithstanding any provision of the general statutes and to the maximum extent permitted by federal law, no individual or group health insurance policy delivered, issued for delivery, renewed, amended or continued in this state on or after January 1, 2020, providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 shall impose a coinsurance, copayment, deductible or other out-of-pocket expense for a covered benefit in an amount that exceeds the lesser of:
Terms Used In Connecticut General Statutes 38a-472j
- Commissioner: means the Insurance Commissioner. See Connecticut General Statutes 38a-1
- Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
- Insurance: means any agreement to pay a sum of money, provide services or any other thing of value on the happening of a particular event or contingency or to provide indemnity for loss in respect to a specified subject by specified perils in return for a consideration. See Connecticut General Statutes 38a-1
- Insured: means a person to whom or for whose benefit an insurer makes a promise in an insurance policy. See Connecticut General Statutes 38a-1
- Policy: means any document, including attached endorsements and riders, purporting to be an enforceable contract, which memorializes in writing some or all of the terms of an insurance contract. See Connecticut General Statutes 38a-1
- State: means any state, district, or territory of the United States. See Connecticut General Statutes 38a-1
(1) The amount paid to the provider or vendor for the covered benefit, including all discounts, rebates and adjustments, by the insurer, health care center, fraternal benefit society, hospital service corporation, medical service corporation or other entity that delivered, issued for delivery, renewed, amended or continued such policy or an intermediary engaged by such insurer, center, society, corporation or entity;
(2) An amount calculated on the basis of the amount charged for the covered benefit by the provider or vendor, less any discount for such covered benefit and any amount due to, or charged by, an entity if such entity is affiliated with, or owned or controlled by, the insurer, health care center, fraternal benefit society, hospital service corporation, medical service corporation or other entity that delivered, issued for delivery, renewed, amended or continued such policy; or
(3) The amount that the insured would have paid to the provider or vendor for the covered benefit without regard to such policy. If the Insurance Commissioner adopts regulations pursuant to subsection (c) of this section, the commissioner may define such amount in such regulations.
(b) Any violation of subsection (a) of this section shall be deemed an unfair method of competition and unfair and deceptive act or practice in the business of insurance under section 38a-816.
(c) The Insurance Commissioner may adopt regulations, in accordance with the provisions of chapter 54, to implement the provisions of this section.