Connecticut General Statutes 38a-495a – Medicare supplement policies and certificates. Minimum required policy benefits and standards. Regulations
(a) As used in this section:
Terms Used In Connecticut General Statutes 38a-495a
- Commissioner: means the Insurance Commissioner. See Connecticut General Statutes 38a-1
- Contract: A legal written agreement that becomes binding when signed.
- 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
- insurance company: includes any person or combination of persons doing any kind or form of insurance business other than a fraternal benefit society, and shall include a receiver of any insurer when the context reasonably permits. 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
- Person: means an individual, a corporation, a partnership, a limited liability company, an association, a joint stock company, a business trust, an unincorporated organization or other legal entity. 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) “Applicant” means (A) in the case of an individual Medicare supplement policy, a person who seeks to contract for insurance benefits or (B) in the case of a group Medicare supplement policy, a proposed certificate holder.
(2) “Certificate” means any certificate delivered or issued for delivery in this state under a group Medicare supplement policy.
(3) “Certificate form” means a form on which the certificate is delivered or issued for delivery by an insurer.
(4) “Commissioner” means the Insurance Commissioner.
(5) “Issuer” means any insurance company, fraternal benefit society, hospital service corporation, medical service corporation, health care center or any other entity that delivers or issues for delivery, in this state, any Medicare supplement policies or certificates.
(6) “Medicare” means the Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965, as then constituted or later amended.
(7) “Medicare supplement policy” means (A) a group or individual policy of accident and sickness insurance or (B) a subscriber contract of hospital service corporations, medical service corporations or health care centers, other than a policy issued pursuant to a contract under Section 1876 of the federal Social Security Act, 42 USC 1395 et seq., or (C) an issued policy under a demonstration project specified in 42 USC 1395ss(g)(1), that is advertised, marketed or designed primarily as a supplement to reimbursements under Medicare for the hospital, medical or surgical expenses of persons eligible for Medicare.
(8) “Policy form” means the form on which the policy is delivered or issued for delivery by the issuer.
(b) Except as otherwise specifically excluded, this section shall apply to all Medicare supplement policies and certificates delivered or issued for delivery in this state on or after July 30, 1992.
(c) This section shall not apply to a policy of one or more employers or labor organizations, or of the trustees of a fund established by one or more employers or labor organizations, or combination thereof, for employees or former employees or a combination thereof, or for members or former members, or a combination thereof, of the labor organizations.
(d) Except as otherwise specifically provided in subdivision (4) of subsection (l) of this section, the provisions of this section shall not apply to insurance policies or health care benefit plans provided to Medicare eligible persons which policies are not marketed or held to be Medicare supplement policies or benefit plans.
(e) No Medicare supplement policy or certificate in force in this state shall contain benefits that duplicate benefits provided by Medicare.
(f) Notwithstanding any other provision of law, a Medicare supplement policy or certificate shall not exclude or limit benefits for losses incurred more than six months from the effective date of coverage because it involved a preexisting condition. The policy or certificate shall not define a preexisting condition more restrictively than a condition for which medical advice was given or treatment was recommended by or received from a physician within six months before the effective date of coverage.
(g) The commissioner shall adopt regulations in accordance with chapter 54 to establish specific standards for policy provisions of Medicare supplement policies and certificates. No requirements of this title relating to minimum required policy benefits, other than the minimum standards contained in this section, shall apply to Medicare supplement policies and certificates. The standards may include but need not be limited to the following: (1) Terms of renewability; (2) initial and subsequent conditions of eligibility; (3) nonduplication of coverage; (4) probationary periods; (5) benefit limitations, exceptions and reductions; (6) elimination periods; (7) requirements for replacement; (8) recurrent conditions; and (9) definitions of terms.
(h) The commissioner shall adopt regulations, in accordance with chapter 54, to establish minimum standards for benefits, claim payments, marketing practices, compensation arrangements and reporting practices for Medicare supplement policies and certificates.
(i) The commissioner may adopt such regulations, in accordance with chapter 54, as are necessary to conform Medicare supplement policies and certificates to the requirements of federal law. Such regulations may include but need not be limited to: (1) Requiring refunds or credits if the policies or certificates do not meet loss ratio requirements; (2) establishing a uniform methodology for calculating and reporting loss ratios; (3) assuring public access to policies, premiums and loss ratio information of issuers of Medicare supplement insurance; (4) establishing a process for approving or disapproving policy forms, certificate forms and proposed premium increases; (5) establishing a policy for holding public hearings prior to approval of premium increases; and (6) establishing standards for Medicare select policies and certificates.
(j) The commissioner may adopt regulations, in accordance with chapter 54, that specify prohibited policy provisions not otherwise specifically authorized which in the opinion of the commissioner, are unjust, unfair or unfairly discriminatory to any person insured or proposed to be insured under a Medicare supplement policy or certificate.
(k) Medicare supplement policies shall return to policyholders benefits which are reasonable in relation to the premiums charged. The commissioner shall adopt regulations, in accordance with chapter 54, to establish minimum standards for loss ratios of Medicare supplement policies on the basis of incurred claim experience, or incurred health care expenses where coverage is provided by a health care center on a service rather than a reimbursement basis, and earned premiums in accordance with accepted actuarial principles and practices.
(l) (1) In order to provide for full and fair disclosure in the sale of Medicare supplement policies, no Medicare supplement policy or certificate shall be delivered in this state unless an outline of coverage is delivered to the applicant at the time application is made.
(2) The commissioner shall adopt regulations in accordance with the provisions of chapter 54 to prescribe the format and content of the outline of coverage required by this subsection. For purposes of this subsection, “format” means style, arrangements and overall appearance, including such items as the size, color and prominence of type and arrangement of text and captions. The outline of coverage shall include: (A) A description of the principal benefits and coverage provided in the policy; (B) a statement of the renewal provisions, including any reservation by the issuer of a right to change premiums; and (C) a statement that the outline of coverage is a summary of the policy issued or applied for and that the policy should be consulted to determine the governing contractual provisions.
(3) The commissioner may prescribe by regulation a standard form and the contents of an informational brochure for persons eligible for Medicare, which is intended to improve the buyer’s ability to select the most appropriate coverage and improve the buyer’s understanding of Medicare. Except for direct response insurance policies, the commissioner may require by regulation that the informational brochure be provided to any prospective insured eligible for Medicare concurrently with the delivery of the outline of coverage. With respect to direct response insurance policies, the commissioner may require by regulation that the prescribed brochure be provided upon request to any prospective insured eligible for Medicare, but in no event later than the time of policy delivery.
(4) The commissioner may adopt regulations, in accordance with chapter 54, for captions or notice requirements, determined to be in the public interest and designed to inform the prospective insured that particular insurance coverages are not Medicare supplement coverages, for all accident and sickness insurance policies sold to persons eligible for Medicare, other than: (A) Medicare supplement policies; or (B) disability income policies.
(5) The commissioner may adopt regulations, in accordance with chapter 54, to govern the full and fair disclosure of the information in connection with the replacement of accident and sickness policies, subscriber contracts or certificates by persons eligible for Medicare.
(m) Medicare supplement policies and certificates shall have a notice prominently printed on the first page of the policy or certificate or attached thereto stating in substance that the applicant shall have the right to return the policy or certificate within thirty days of its delivery and to have the premium refunded if, after examination of the policy or certificate, the applicant is not satisfied for any reason. Any refund made pursuant to this section shall be paid directly to the applicant by the issuer in a timely manner.
(n) Every issuer of Medicare supplement insurance policies or certificates in this state shall provide a copy of any Medicare supplement advertisement intended for use in this state, whether through written, radio or television medium to the commissioner for his review or approval to the extent required by regulations, adopted pursuant to section 38a-819.
(o) In addition to any other applicable penalties for violations of this title, the commissioner may require issuers violating any provision of this section or any regulations promulgated pursuant to this section to cease marketing any Medicare supplement policies or certificates in this state which is related directly or indirectly to a violation or take such actions as are necessary to comply with the provisions of this section, or both.