Current through March 14, 2024
(a)
Extension
of benefits. In accordance with section
38a-546
of the Connecticut General Statutes, every group insurance policy shall provide
a reasonable provision for extension of benefits in the event of total
disability at the date of discontinuance of the group insurance policy, as
follows:
(1) In the case of a group life plan
that contains a disability benefit extension of any type (e.g., premium waiver
extension, extended death benefit in event of total disability, or payment of
income for a specified period during total disability), the discontinuance of
the group insurance policy shall not operate to terminate such
extension.
(2) In the case of a
group disability income protection policy or group hospital confinement
indemnity policy, discontinuance of the policy during a disability shall have
no effect on benefits payable for that disability or confinement.
(3) In the case of a group health insurance
plan, the extension of benefits provision shall provide coverage set forth in
subparagraphs (A), (B), and (C) of this subdivision.
(A) No succeeding carrier. When there is no
succeeding group health insurance plan sponsored by the employer and insured by
another carrier, for covered individuals who were confined to a health care
facility or totally disabled, on the date the policy is discontinued, the group
health insurance plan shall provide coverage for the confinement including
professional services and supplies rendered during the confinement in the
health care facility and for all services related to the disabling condition,
as applicable, without premium payment, according to the terms of its plan.
(i) Length of extension. The extension will
apply until the date the covered individual is not confined to a health care
facility, or for those not confined to a health care facility - not totally
disabled, or the date that is twelve calendar months following the date the
policy was discontinued, whichever is earlier.
(ii) Submission of claim. Extension of
benefits will be available provided that evidence of the facility confinement,
if any, and any disabling condition is submitted within one year of the
termination of the plan and claims for coverage are submitted in accordance
with the plan terms.
(B)
Succeeding carrier for person confined in a health care facility. When the
group health insurance plan is replaced by a succeeding group health insurance
plan sponsored by the employer and insured by another carrier, for covered
individuals who were confined to a health care facility on the date the policy
is discontinued, the prior group health plan shall provide coverage for the
confinement including professional services and supplies rendered during the
confinement in the health care facility, without premium payment.
(i) Length of extension. The extension will
apply until the date the covered individual is not confined to a health care
facility, or the date that is twelve calendar months following the date the
policy was discontinued, whichever is earlier.
(ii) Submission of claim. Extension of
benefits will be available provided that evidence of facility confinement and
any disabling condition is submitted within one year of the termination of the
plan and claims for coverage are submitted in accordance with the plan
terms.
(iii) Transition of care.
The succeeding carrier shall be responsible for all other coverage for the
individual, including transition of care benefits that provide the individual
with a reasonable opportunity to use their current health care provider(s) for
a period of time that is clinically appropriate for the treatment of the
condition related to the confinement. During the transitional period, benefits
under the succeeding carrier's plan for treatment of the condition related to
the confinement will not be reduced because of lack of participation in the
succeeding carrier's network or lack of certification by the succeeding carrier
for services pre-certified by the prior carrier. Nothing herein shall be
construed as authorizing or requiring medical necessity certification
procedures between the managed care organization and the provider that are not
set forth in the contract between the managed care organization and the
provider.
(C) Succeeding
carrier for a totally disabled person not confined in a health care facility.
When the group health insurance plan is replaced by a succeeding group health
insurance plan sponsored by the employer and insured by another carrier, for
covered individuals who are totally disabled but not confined to a health care
facility on the date the policy is discontinued, the succeeding group health
plan shall provide coverage in accordance with the plan terms.
(i) Transition of care. The succeeding
carrier shall be responsible for all coverage for the totally disabled
individual, including transition of care benefits that provide the individual
with a reasonable opportunity to use their current health care provider(s) for
a period of time that is clinically appropriate for the treatment of the
disabling condition. During the transitional period, benefits under the
succeeding carrier's plan for treatment of the disabling condition will not be
reduced because of lack of participation in the succeeding carrier's network or
lack of certification by the succeeding carrier for services pre-certified by
the prior carrier. Nothing herein shall be construed as authorizing or
requiring medical necessity certification procedures between the managed care
organization and the provider that are not set forth in the contract between
the managed care organization and the provider.
(b)
Continuation of
benefits. Pursuant to sections
38a-546
and
38a-538 of the
Connecticut General Statutes, in the case of a group health insurance plan, the
continuation of benefits provision shall contain the following provisions for
continuation of benefits:
(1) Regardless of an
individual's eligibility for other group insurance, during an employee's
absence due to illness or injury, coverage for such employee and their covered
dependents during continuance of such illness or injury or for up to twelve
months from the beginning of such absence, whichever is sooner. Such individual
may be required to contribute up to that portion of the premium the individual
would have been required to contribute had the employee remained an active
covered employee. This provision does not obligate the employer to pay the
individual's premium if the individual does not pay the premium.
(2) In any case in which coverage has been
continued pursuant to section
38a-546
of the Connecticut General Statutes, the individual may be required to pay up
to the rate allowed by the Consolidated Omnibus Budget Reconciliation Act of
1985 ( P.L. 99-272 ), as amended from time to time (COBRA). This provision does
not obligate the employer to pay the individual's premium if the individual
does not pay the premium except, pursuant to section 38a-554(b) of the
Connecticut General Statutes, upon termination of the group plan, coverage for
covered individuals who were totally disabled on the date of termination of the
group plan shall be continued without premium payment during the continuance of
such disability for a period of twelve calendar months following the calendar
month in which the plan was terminated, provided claim is submitted for
coverage within one year of the termination of the plan.
(3) Any individual whose coverage has been
continued, as of the date the contract is replaced, shall be covered by the
succeeding carrier's plan of benefits for the duration of the continuation of
coverage period, provided that within 31 days after the date of the replacement
the succeeding carrier is paid the premium necessary to continue coverage for
the individual.
(c)
Conversion. All group insurance policies shall include a provision
explaining the conversion privileges available upon termination of coverage or
at the end of an extension of benefits provision.
(d)
Pre-Existing Condition. In
the case of a pre-existing conditions limitation included in the succeeding
carrier's plan, the level of benefits applicable to preexisting conditions of
persons becoming covered by the succeeding carrier's plan in accordance with
this subsection during the period of time this limitation applies under the new
plan shall be the lesser of:
(1) The benefits
of the new plan determined without application of the pre-existing conditions
limitation, or
(2) The benefits of
the prior plan.
(e) In
any situation where a determination of the prior carrier's benefit is required
by the succeeding carrier, at the succeeding carrier's request the prior
carrier shall furnish a statement of the benefits available or pertinent
information, sufficient to permit verification of the benefit determination or
the determination itself by the succeeding carrier.
(f) Any applicable extension of benefits or
accrued liability shall be described in every group insurance policy. The
benefits payable during any period of extension or accrued liability may be
subject to the group insurance policy regular benefit limitations (e.g.,
benefits ceasing at exhaustion of a benefit period or of maximum
benefits).
