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Summary of differences between federal and state regulations
Employee health plans are generally covered under the federal jurisdiction of the Employee Retirement Income secuity Act (ERISA).
Federal ERISA plans generally do not have to comply with state laws. ERISA rules preempt or block state laws that relate to ERISA plans. State insurance laws, however, do apply. Connecticut statutes include the following provisions:
If a company has 20 or fewer employees, health plans may not reduce the coverage provided to any employee or any employee's spouse solely because he has reached the age of sixty-five and is eligible for Medicare benefits except to the extent such coverage is provided by Medicare. If a company has twenty or more employees, it must entitle any employee who has attained the age of sixty-five and any employee's spouse who has attained the age of sixty-five to group hospital, surgical or medical insurance coverage under the same conditions as any covered employee or spouse who is under the age of sixty-five. §38a-543
Group plans that provide coverage for prescription drugs may not require plan participants to obtain prescription drugs from a mail order pharmacy as a condition of obtaining benefits for such drugs. §38a-544
Group plans must provide benefits for the diagnosis and treatment of mental or nervous conditions.
In the case of benefits payable for the services of a licensed physician or psychologist, such benefits shall be payable for the same services when such services are rendered by:
- A clinical social worker,
- A certified social worker,
- A licensed marital and family therapist,
- A certified marital and family therapist,
- A licensed alcohol and drug counselor, or
- A licensed professional counselor.
§38a-514
Group health plans that provide coverage of a dependent child of an employee that terminates upon attainment of the limiting age for dependent children must also provide that attainment of the limiting age does not terminate the coverage of the child if at such date the child is incapable of self-sustaining employment by reason of mental or physical handicap, and chiefly dependent upon such employee or member for support and maintenance. §38a-515
Group health plans that provide family coverage must also provide benefits for newly born children from the moment of birth. Coverage must include injury and sickness including necessary care and treatment of medically diagnosed congenital defects and birth abnormalities. §38a-516
Plans must cover children legally placed for adoption with an employee who is an adoptive parent or a prospective adoptive parent, even though the adoption has not been finalized, provided the child lives in the household of the employee and the child is dependent upon the employee for support and maintenance. Coverage must include necessary care and treatment of medically diagnosed congenital defects and birth abnormalities. §38a-549
Group health plans providing family coverage must provide at least $6,400 annual coverage for medically necessary early intervention services for children from birth to three years old. For a child with autism spectrum disorder, however, who is receiving early intervention services, the maximum benefit available through early intervention providers shall be $50,000 per child per year and an aggregate benefit of $150,000 per child over the total three-year period. §38a-516a
Group health plans providing family coverage must provide coverage for hearing aids for children twelve years of age or younger. The policy may limit the provision to $1,000 every 24 months. §38a-516b
Licensed dentists are included as physicians or doctors in group health plans. §38a-517
Plans must provide coverage for general anesthesia, nursing, and related hospital services provided in conjunction with in-patient, outpatient or one-day dental services under certain conditions. §38a-517a
Other mandatory coverage includes the following:
- Accidental ingestion of controlled drugs, §38a-518
- Hypodermic needles and syringes, §38a-518a
- Off-label drug prescriptions, §38a-518b
- Low protein modified food products, amino acid modified preparations and specialized formulas, §38a-518c
- Diabetes testing and treatment, §38a-518d
- Diabetes outpatient self-management training, §38a-518e
- Certain prescription drugs removed from formulary, §38a-518f
- Prostate cancer screening, §38a-518g
- Certain Lyme disease treatments, §38a-518h
- Pain management, §38a-518i
- Ostomy (colostomy, ileostomy and urostomy)-related supplies, §38a-518j
- Colorectal cancer screening, §38a-518k
- Reimbursement for home health care, 38a-520
- Necessary ambulance service, 38a-525
- Partners, sole proprietors, and corporate officers for work-related injuries, 38a-527
- Services of physician assistants, certified nurse practitioners, certified psychiatric-mental health clinical nurse specialists, and certified nurse-midwives, 38a-526
- Service provided by the Veterans' Home and Hospital, 38a-529
- Treatment of medical complications of alcoholism, 38a-533
- Chiropractic services, 38a-534
- Preventive pediatric care up to age 6, 38a-535
Plans that provide coverage for physical therapy must provide coverage for occupational therapy, 38a-524
Plans cannot require an enrollee to obtain approval (preauthorization) before calling 9-1-1, 38a-525a
Group health plans must provide coverage for mammograms and preventive pediatric care, if 51 percent or more of the covered employees work in Connecticut. The forms of such policies shall be submitted to the Insurance Commissioner for approval. §38a-531
Effective as of October 1, 2005, group health plans must cover the medically necessary expenses of the diagnosis and treatment of infertility. The policy may limit such coverage to participants under 40 years old and impose some lifetime maximum benefits. The coverage may also be limited to participants who have been covered for at least 12 months. §38a-536 (the state statute site had not been updated at the time of this posting).
If the plan is cancelled or discontinued, employees must be furnished notice of cancellation or discontinuance within 15 days. 38a-537
If a husband and wife are employed by the same employer and are both eligible for coverage, they shall not be required — as a condition of their employment or as a condition of coverage under such plan — to pay any premium which does not result in greater coverage than would be provided if only one of them were eligible to participate in such group plan. §38a-540
Plans must allow the spouse of any employee participating in a plan offered by the same employer to be covered as an employee in addition to being covered as a dependent of such participating employee. §38a-541
Plans must cover treatment of leukemia, including outpatient chemotherapy, reconstructive surgery, cost of any nondental prosthesis, including any maxillo-facial prosthesis used to replace anatomic structures lost during treatment for head and neck tumors or additional appliances essential for the support of such prosthesis, and outpatient chemotherapy following surgical procedures in connection with the treatment of tumors. §38a-542
Plans must cover routine patient care costs associated with cancer clinical trials as long as the trials are conducted under the auspices of an independent peer-reviewed protocol. §38a-542a
Discrimination on the basis of age is prohibited. §38a-543
Mail order pharmacy requirement is prohibited. §38a-544
Employers with 25 or more employees at all times during the preceding calendar year and contributes to a group health insurance plan that restricts the selection of dental providers, must also offer each participant the option of selecting alternative coverage that permits the participant to obtain dental services from any licensed dentist of his choice. §38a-545
Comprehensive health care statutes are found at §38a-551 through §38a-559. Under Public Act 05-271, comprehensive health care plans issued through the Health Reinsurance Association must provide coverage, under the terms and conditions of the plan, for the preexisting conditions of any group member or dependent who is newly insured under the plan on or after October 1, 2005, and was previously covered for such preexisting condition under the terms of the group member's or dependent's preceding qualifying coverage, provided the preceding qualifying coverage was continuous to a date less than 120 days prior to the effective date of the new coverage, exclusive of any applicable waiting period. This applies, except in the case of a newly insured group member whose preceding qualifying coverage was terminated due to an involuntary loss of employment. In this case, the preceding qualifying coverage must have been continuous to a date not more than 150 days prior to the effective date of the new coverage under the plan, exclusive of any applicable waiting period, provided the requirements of this subdivision shall only apply if the newly insured group member or dependent applies for such succeeding coverage not later than 30 days after the first day of the member's or dependent's initial eligibility.
With respect to a group member or dependent who was newly insured under the plan on or after October 1, 2005, and was previously covered under qualifying coverage, but was not covered under such qualifying coverage for a preexisting condition, the plan must credit the time the group member or dependent was previously covered by qualifying coverage to the exclusion period of the preexisting condition provision. This applies as long as the preceding qualifying coverage was continuous to a date less than 120 days before the effective date of the new coverage, exclusive of any applicable waiting period under such plan. This applies except in the case of a newly insured group member whose preceding qualifying coverage was terminated due to an involuntary loss of employment. In this case, the preceding qualifying coverage must have been continuous to a date not more than 150 days prior to the effective date of the new coverage, exclusive of any applicable waiting period, provided the newly insured group member or dependent applies for the succeeding coverage not later than 30 days after the first day of the member's or dependent's initial eligibility.
The Act added subsection (k) to 38a.553.
Small employer health care statutes are found at §38a-564 through §38a-574
Plans must provide for coverage of services of optometrists. §20-138d
Discrimination on the basis of physical disability, mental retardation, exposure to diethylstilbestrol, or domestic violence is prohibited. §38a-816
Reimbursement must not be denied because of race, color or creed. §38a-816
Employers with 25 or more employees must, at the request of a health care center, include in their plan the option of membership in a health care center. §31-51p
Effective October 1, 2009, you may choose to not pay the health insurance premium of an employee (and dependents) who is terminated for reasons other than layoff or if the employee voluntarily terminated employment, after the date of the termination. The insurer, hospital, and so on, must credit the employer the amount of any premium paid, if the employer notifies the insurer within 72 hours after the termination. The insurer (hospital, and so on) is also to provide the employer a notice indicating the employer's responsibility to remit to the terminated employee his or her portion of the credited premium (see Public Act 09-126).
Connecticut Public Act 09-148 established the state SustiNet Plan, an exchange set up under the federal health care reform law (Patient Protection and Affordable Care Act)
State
Contact
Connecticut Insurance Department
Regulations
General Statutes of Connecticut, Title 38a, chapter 700c www.cga.ct.gov/current/pub/chap_700c.htm
General Statutes of Connecticut, Title 20, chapter 380, §20-138d www.cga.ct.gov/current/pub/chap_380.htm#sec_20-138d
General Statutes of Connecticut, Title 31, chapter 557, §51-51p www.cga.ct.gov/current/pub/chap_557.htm#sec_31-51p
For more information on health benefits for women, see the topic Women’s Health Rights.
Federal
Contact
Employee Benefits Security Administration (EBSA)
Regulations
29 CFR chapter XXV (Parts 2509 – 2590)