Conn. Agencies Regs. § 38a-528a-4 - Minimum standards

No group insurance policy or certificate shall be advertised, solicited or issued for delivery in this state as a group short-term care policy or certificate that does not meet the minimum standards set forth in this section. The standards set forth in this section are minimum standards and do not preclude the inclusion of other provisions or benefits that are not inconsistent with these standards.

(a) Continuation.

(1) All group short-term care policies and certificates shall include a provision which allows the certificate holder to continue coverage or convert to an individual short-term care policy in the event of the cancellation, nonrenewal or termination of the group policy. Conversion is to be made without evidence of insurability and without pre-existing conditions limitations or waiting periods, with an effective date that coincides with the date coverage ceased under the group short-term care policy.

(2) Any insured individual whose eligibility for group short-term care coverage is based upon his or her relationship to another person shall be entitled to continue coverage under the group short-term care policy or convert to an individual short-term care policy upon termination of the relationship by death or dissolution of marriage. Conversion is to be made without evidence of insurability, without pre-existing conditions limitations or waiting periods, and with an effective date that coincides with the date coverage ceased under the group short-term care policy

(3) If a group short-term care policy is replaced by another policy or contract issued to the same policyholder, the succeeding carrier shall offer coverage to all persons covered under the previous policy or contract on the date of its termination. Coverage shall be made available without evidence of insurability or pre-existing conditions limitations or waiting periods and with an effective date that coincides with the termination of coverage under the preceding policy.

(b) A group short-term care policy or certificate shall not deny a claim for loss that occurs or confinement that begins more than six (6) months after the effective date of the policy for a preexisting condition. The group policy or certificate shall not define a pre-existing condition more restrictively than a condition for which medical advice was given or treatment was recommended by or received from a physician within six (6) months immediately preceding the effective date of coverage.

(c) A group short-term care policy or certificate shall not indemnify against losses resulting from sickness on a different basis from losses resulting from accidents.

(d) Limitations and Exclusions . A group short-term care policy or certificate shall not include limitations or exclusions that are more restrictive than the following:

(1) PRE-EXISTING CONDITIONS LIMITATION - This policy or certificate does not pay benefits for a loss that occurs or confinement that begins within six (6) months after the effective date of the policy or certificate as a result of a pre-existing condition.

(2) OTHER EXCLUSIONS - This policy or certificate does not cover:

(A) Loss that is caused by declared or undeclared war or any act thereof;

(B) Loss that is caused by mental disease or disorder without demonstrable organic disease;

(C) Loss that is caused by suicide or any attempt thereof (while sane or insane), or intentionally self inflicted injury;

(D) Confinement in a government institution unless a charge is made that the insured is obligated to pay;

(E) Confinement due to alcoholism or drug addiction;

(F) Confinement in a hospital;

(G) Confinement or care received outside of the United States;

(H) Loss that is caused by participation in a felony, riot or insurrection;

(I) Services for which benefits are payable under any state or federal workers' compensation, employers liability or occupational disease law, or any motor vehicle no-fault law;

(J) Services provided by the insured's immediate family, unless a benefit specifically states that a member of the insured's immediate family can provide covered care;

(K) Services for which no charge is normally made in the absence of insurance;

(L) Medications, whether prescription or non-prescription; or

(M) Loss that occurs while this policy or certificate is not in force.

(3) A policy or certificate may provide that its benefits shall not duplicate benefits payable by Medicare or that would be payable by Medicare but for the application of a deductible or coinsurance amount.

(e) No group short-term care policy or certificate shall use waivers to exclude, limit or reduce coverage or benefits for specifically named or described pre-existing diseases or physical conditions.

(f) Group short-term care policies or certificates shall make reasonable provision for waiver of premium. As to benefits for institutional confinement, this requirement is met if the policy or certificate provides for a waiver of premium after benefits have been paid for a period not to exceed thirty (30) consecutive days inclusive of any elimination period, and thereafter during the continuance of the consecutive days for which benefits are paid.

(g) Group short-term care certificates, other than those issued pursuant to direct response solicitation, shall have a notice prominently printed on the first page of the certificate or attached thereto stating in substance that the certificate holder shall have the right to return the certificate to the insurer or its agent within thirty (30) days of its delivery and to have the premium refunded if, after examination of the certificate, the certificate holder is not satisfied for any reason. Group short-term care certificates issued pursuant to a direct response solicitation shall have a notice prominently printed on the first page or attached thereto stating in substance that the certificate holder shall have the right to return the certificate to the insurer within thirty (30) days of its delivery and to have the premium refunded if, after examination of the certificate, the certificate holder is not satisfied for any reason.

(h) Group short-term care policies or certificates shall not condition benefits upon prior hospitalization or institutionalization.

(i) Short-term care policies and certificates shall include a provision that states that upon notification to the insurer of an insured's death, the insurer will refund on a pro-rata basis any part of a periodic premium paid by such insured that applies to the period after death.

(j) Short-term care policies and certificates shall not have an elimination period greater than thirty (30) days of confinement.

(k) Group short-term care policies and certificates shall include a provision that the policy shall be incontestable, except for nonpayment of premium, after it has been in force for two (2) years from its date of issue.

(l) Extension of Benefits. Termination of group short-term care insurance shall be without prejudice to any benefits payable for institutionalization if such institutionalization began while the group short-term care insurance was in force and continues without interruption after termination. Such extension of benefits beyond the period the group short-term care insurance was in force may be limited to the duration of the benefit period or to payment of the maximum benefits, and may be subject to any policy waiting period and all other applicable provisions of the policy or certificate.

(m) The premiums charged to an insured for group short-term care insurance shall not increase due solely to either the increasing age of the insured at ages beyond sixty-five (65) or the duration the insured has been covered under the policy.

(n) Payment of Benefits. A group short-term care policy or certificate that provides for the payment of benefits based on standards described as ''usual and customary,'' '' reasonable and customary'' or words of similar import shall include a definition of such terms and an explanation of such terms in its accompanying outline of coverage.

(o) A group short-term care policy or certificate that only provides benefits for confinement in the insured's own home shall include a statement to that effect on the first page of the certificate in bold print.

(p) A group short-term care policy or certificate that provides benefits for home health care shall not limit or exclude such benefits by:

(1) Requiring that the insured receive skilled care in a skilled nursing facility rather than in the home, if home care services were not provided or available;

(2) Requiring that the insured first or simultaneously receive nursing or therapeutic services, or both, in a home, community or institutional setting before home health care services are covered;

(3) Limiting eligible services to services provided by registered nurses or licensed practical nurses;

(4) Requiring that a nurse or therapist provide services covered by the policy that can be provided by a home health aide or other home care worker acting within the scope of his or her licensure or certification;

(5) Excluding coverage for personal care services provided by a home health aide;

(6) Requiring that the provision of home health care services be at a level of certification or licensure greater than that required by the eligible service;

(7) Requiring that the insured have an acute condition before home health care services are covered;

(8) Limiting benefits to services provided by Medicare-certified agencies or providers; or

(9) Excluding coverage for adult day care, hospice care, skilled nursing care, or physical, occupational, respiratory or speech therapy.

(q) The application for every group short-term care certificate shall include a section inviting the applicant to give the name of an individual who is to receive notice of lapse concurrently with any such notice sent to the certificate holder. Along with space for the name and address of such individual, this section shall include a notice to the applicant as follows (or in substantially similar language): YOU WILL RECEIVE NOTICE IF YOUR COVERAGE IS ABOUT TO LAPSE (TERMINATE) BECAUSE YOU HAVE NOT PAID PREMIUMS. WE WILL BE GLAD TO SEND A COPY OF THIS NOTICE TO ANOTHER PERSON, IF YOU WOULD LIKE. THAT PERSON WILL NOT BE RESPONSIBLE FOR PAYMENT OF THE PREMIUM, AND YOU WILL ALWAYS RECEIVE YOUR OWN COPY OF THE NOTICE. IF YOU WANT AN EXTRA COPY SENT TO ANOTHER PERSON, PLEASE GIVE US THAT PERSON'S NAME AND ADDRESS.

(r) No group short-term care certificate shall contain a coordination of benefits provision unless such policy is issued on a non-contributory basis.

Notes

Conn. Agencies Regs. § 38a-528a-4

Effective 8/24/2018