OLR RESEARCH REPORT
June 11, 2008
2008-R-0326
PROPOSED AND ENACTED MANDATED INSURANCE BENEFITS IN
CONNECTICUT AND MEDICARE BENEFITS
By: Janet L. Kaminski Leduc, Senior Legislative Attorney
You asked for a list of (1) mandated health insurance benefits that the
legislature proposed and enacted in 2007 and 2008, (2) benefits
Connecticut law requires health insurance policies to include, and (3)
what Medicare covers.
SUMMARY
In Connecticut, health insurance laws are contained in Chapter 700c
of the general statutes. Due to federal preemption, state insurance
mandates generally do not apply to self-insured plans. (For more
information, see OLR Research Report 2005-R-0753, Self-Insurance
Benefit Plans and Insurance Mandates.)
The tables below include the following information:







Table 1
2007;
Table 2
Table 3
2008;
Table 4
Table 5
Table 6
and
Table 7
Mary M. Janicki, Director
Phone (860) 240-8400
FAX (860) 240-8881
http://www.cga.ct.gov/olr
- health insurance mandates proposed, but not enacted, in
- health insurance mandates enacted in 2007;
- health insurance mandates proposed, but not enacted, in
- health insurance mandates enacted in 2008;
- mandated policy benefits;
- health care providers whose services must be covered;
- health care facilities whose services must be covered.
Connecticut General Assembly
Office of Legislative Research
Room 5300
Legislative Office Building
Hartford, CT 06106-1591
Olr@cga.ct.gov
Medicare is health insurance for people age 65 or older, under age 65
with certain disabilities, and any age with end-stage renal disease
(permanent kidney failure requiring dialysis or a kidney transplant).
Medicare has several parts: Part A (hospital insurance), Part B (medical
insurance), Part C (Medicare Advantage plan – an alternative to “original”
Medicare), and Part D (Medicare prescription drug plan).
This report focuses on “original” Medicare (Parts A and B). Medicare
Part A helps cover inpatient care in hospitals (critical access hospitals
and inpatient rehabilitation facilities), skilled nursing facilities after a
hospital stay, religious nonmedical health care institutions, home health
care services, and hospice care. Medicare doesn’t cover custodial or
long-term care. Medicare Part B helps cover medically-necessary
services like doctors’ services, outpatient care, and other medical services
that Part A doesn’t cover.
Table 8 below includes more details on what Medicare Parts A and B
cover. More information is available in the federal government
publication regarding Medicare, which may be viewed online at:
http://www.medicare.gov/Publications/Pubs/pdf/10116.pdf.
PROPOSED AND ENACTED HEALTH INSURANCE MANDATES
Table 1: Health Insurance Mandates: 2007 Proposed But Not Enacted
Bill
SB 55
SB 67
SB 73
SB 164
SB 165
SB 166
Title
An Act Requiring Health Insurance
Coverage For Medical Supplies For
Persons With Lymphedema
An Act Expanding Health Insurance
Coverage For Dependent, Unmarried
Children
An Act Expanding Insurance
Coverage For Hearing Aids For
Children
An Act Requiring Heath Insurance
Coverage For Emergency Medical
Conditions
An Act Requiring Heath Insurance
Coverage For Colonoscopies For
Colon Cancer Survivors
An Act Increasing Insurance
Coverage For Hearing Aids For
Children
June 11, 2008
Description
To require coverage for compression
bandages, garments, and supplies for
people with lymphedema.
To require individual health insurance
policies and group comprehensive health
care plans to provide that coverage of a
dependent, unmarried child terminates
when the child turns age 24, regardless of
student status.
To require coverage for hearing aids as
durable medical equipment for children
under age 19, instead of 13.
To require coverage for the treatment of
emergency medical conditions.
To require full coverage for colonoscopies for
colon cancer survivors.
To require coverage for hearing aids for
children age 18 or younger and permit the
policy to limit the benefit to $2,500 per ear
in a 36-month period.
Page 2 of 18
2008-R-0326
Table 1: -ContinuedBill
SB 214
SB 390
Title
An Act Expanding Insurance
Coverage For Hearing Aids For
Children
An Act Expanding Insurance
Coverage For Persons With Diabetes
SB 394
An Act Concerning Coverage For
Chiropractic Care
SB 586
An Act Requiring Heath Insurance
Coverage For Dentures
An Act Concerning Health Insurance
Coverage For Bone Marrow Testing
An Act Requiring Health Insurance
Coverage For Medical Supplies For
Persons With Lymphedema
An Act Expanding Insurance
Coverage For Hearing Aids
SB 673
SB 815
SB 816
SB 817
SB 818
An Act Extending Health Insurance
Coverage For Dependent, Unmarried
Children
An Act Requiring Health Insurance
Coverage For Fertility Procedures
SB 819
An Act Concerning Health Insurance
Coverage For Participation In Clinical
Trials
SB 1014
An Act Concerning Health Insurance
Coverage For Bone Marrow Testing
HB 5053
An Act Requiring Health Insurance
Coverage For Mouth Guards For
Persons With Temporomandibular
Joint Dysfunction (TMJ)
An Act Requiring Health Insurance
Coverage For Supplies For The
Treatment Of Lymphedema
An Act Requiring Health Insurance
Coverage For Inpatient Substance
Abuse Treatment
HB 5303
HB 5307
June 11, 2008
Description
To require coverage for hearing aids for
children age 18 eighteen or younger.
To require full coverage for all equipment,
supplies, and prescriptions for all diabetes
types.
To permit a managed care plan that
includes coverage for chiropractic care may
include a reasonable deductible, copayment,
or coinsurance amount that is the lesser of:
(1) the amount due for a primary care
physician, or (2) 25% of the fee due to the
chiropractor under the policy or for the
service provided.
To require coverage for dentures.
To require coverage for the cost of testing for
bone marrow donation.
To require coverage for compression
bandages, garments, and supplies for
people with lymphedema.
To require coverage for hearing aids of (1)
$2,500 per hearing aid, per ear, every three
years for people under age 19 and (2)
$1,000 per hearing aid, per ear, every three
years for people age 19 or older.
To provide that coverage of a dependent,
unmarried child terminates when the child
turns age 30.
To require coverage for fertility tests,
treatments, and procedures for people up to
age 45.
To require coverage for routine patient care
costs associated with clinical trials for the
treatment of serious or life-threatening
diseases.
To require coverage for expenses arising
from human leukocyte antigen testing, also
referred to as histocompatibility locus
antigen testing, for A, B, and DR antigens
for use in bone marrow transplantation.
To require coverage for mouth guards for
people with TMJ.
To require coverage for physician-prescribed
supplies for lymphedema treatment as
durable medical equipment.
To require coverage for inpatient substance
abuse treatment for at least seven days for
any insured person who requests it, if he or
she used a substance within the last 14
days.
Page 3 of 18
2008-R-0326
Table 1: -ContinuedBill
HB 5332
Title
An Act Increasing Access To Chronic
Medication
HB 5667
An Act Extending Health Insurance
Coverage For Dependent, Unmarried
Children Who Are Veterans
HB 5668
An Act Prohibiting Higher
Copayments For Ninety-Day
Prescriptions
HB 5672
An Act Requiring Mental Health
Insurance Coverage For Situational
Depression Due To Bereavement
An Act Extending Health Insurance
Coverage For Dependent Children
HB 6055
HB 6282
HB 6656
HB 6662
HB 6663
HB 6895
An Act Requiring Health Insurance
Coverage For Hearing Aids For Adults
An Act Requiring Health Insurance
Coverage For Wigs For Individuals
With Permanent Hair Loss
An Act Requiring Health Insurance
Coverage For The Treatment Of
Ectodermal Dysplasias
An Act Requiring Health Insurance
Coverage For Wound Care For
Individuals With Epidermolysis
Bullosa
An Act Expanding Benefits Under
Dental Plans
June 11, 2008
Description
To prohibit coverage for outpatient
prescription drugs from requiring more than
a single copayment for a 90-day supply of
any covered chronic medication (prescribed
for continuous use for more than 12
months).
To provide for coverage of a dependent,
unmarried child who is a veteran from age
22 until he or she receives a degree, not to
exceed a bachelor’s degree, at an accredited
institution of higher education.
To prohibit charging an insured person a
higher copayment for a 90-day supply of a
prescription than for a 30-day or 60-day
supply of the same prescription, provided
the person purchases the 90-day supply at
one time.
To require coverage for situational
depression due to bereavement, where a
depression designation is not required.
To extend health insurance coverage for a
dependent child until age 25 or for as long
as he or she is enrolled as a full-time
student at an accredited institution of
higher education, and to allow health
insurers to reflect the cost of the coverage in
the policy premium.
To require coverage for 80% of the cost of
hearing aids for people age 18 or older.
To require coverage for a physicianprescribed wig for any person who suffers
permanent hair loss for any medical reason.
To require coverage for the treatment of
ectodermal dysplasias.
To require coverage for wound care for
people with epidermolysis bullosa.
To require dental plans that cover silver or
mercury dental fillings to provide equivalent
or greater coverage for nonmercury or
composite fillings if the insured person
requests such fillings.
Page 4 of 18
2008-R-0326
Table 2: Health Insurance Mandates: 2007 Enacted
Public Act
07-67
(sSB 389)
Title
An Act Concerning
Hospitalization At An Out-OfNetwork Facility During
Treatment In Cancer Clinical
Trials
07-75
(sHB 7055)
An Act Concerning Medical
Necessity And External Appeals
07-113
(sSB 1214)
An Act Concerning Postclaims
Underwriting
07-185
(SB 1484)
An Act Concerning The
Healthfirst Connecticut And
Healthy Kids Initiatives
07-197
(SB 66)
An Act Expanding Insurance
Coverage For Specialized
Formulas For Children
07-252
(sHB 7163)
An Act Concerning Revisions
To Statutes Relating To The
Departments Of Public Health
And Social Services And Town
Clerks
An Act Implementing The
Provisions Of The Budget
Concerning Human Services
And Public Health
07-2, JSS
(HB 8002)
June 11, 2008
Description
Provides that coverage for cancer clinical trials
includes treatment at an out-of-network facility if
(1) it is unavailable at an in-network facility and
(2) the clinical trial sponsors are not paying for it.
The out-of-network hospital treatment must be
available at no greater cost to the patient than if
treatment was available at an in-network facility.
Requires insurers, HMOs, and other entities to
include a specified definition of “medically
necessary” or “medical necessity” in health
insurance policies.
Removes from the preexisting condition definition
for individual health insurance policies a physical
or mental condition that manifested itself during
the 12 months before coverage became effective.
Thus, it defines a preexisting condition as a
physical or mental condition for which medical
advice, diagnosis, care, or treatment was
recommended or received during the 12 months
before coverage became effective. Imposes
preexisting condition exclusion limitations on
short-term policies.
Raises, from age 23 to 26, the age to which group
comprehensive and individual health insurance
policies that cover children must do so. The act
eliminates the requirements that children be
dependent or full-time students and limits the
continuing coverage to those who live in
Connecticut.
Requires coverage for medically necessary
specialized formulas administered under a
physician's direction for children up to age 12.
Prior law was until age eight.
Changes the name of critical access hospitals to
mobile field hospitals. By law, health insurance
policies must provide coverage for such hospitals.
Amends PA 07-185 with respect to insurance
coverage for children by extending coverage to
children who attend accredited out-of-state
colleges or who live in another state with a
custodial parent.
Requires coverage for blood lead screening and
risk assessments primary care providers order
pursuant to § 48 of the act.
Page 5 of 18
2008-R-0326
Table 3: Health Insurance Mandates: 2008 Proposed But Not Enacted
Bill
SB 276
Title
An Act Expanding Health Insurance
Coverage For Hearing Aids For
Children
An Act Concerning Insurer Payment
For Mental Health Residential Care
SB 278
SB 280
An Act Concerning Health Insurance
Coverage For Bone Marrow Testing
An Act Prohibiting Copayments For
Preventive Care
SB 478
HB 5521
An Act Concerning Health Insurance
Coverage For Wound Care For
Individuals With Epidermolysis
Bullosa
An Act Providing Insurance
Coverage For Prostheses
An Act Concerning Health Insurance
Coverage For Supplies For The
Treatment Of Lymphedema
An Act Concerning Ostomy Supplies
HB 5527
HB 5691
HB 5697
Description
To extend coverage for hearing aids to children
up to age 18, instead of 12.
To require payment of residential treatment
services for all insureds requiring that level of
care and to eliminate the three-day acute
hospitalization requirement immediately
preceding such confinement.
To require coverage for bone marrow testing.
To prohibit insurers from imposing a
copayment, deductible, or other out-of-pocket
expense for preventive care services.
To require coverage for wound care supplies for
people with epidermolysis bullosa.
To require coverage for certain prosthetic
devices.
To require coverage for the treatment of
lymphedema.
To increase the required coverage for ostomy
supplies by removing the $1,000 annual
benefit maximum.
Table 4: Health Insurance Mandates: 2008 Enacted
Public Act
08-125
(sSB 167)
Title
An Act Concerning Benefits For
Inpatient Treatment Of Serious
Mental Or Nervous Conditions
08-132
(sHB 5696)
An Act Requiring Insurance
Coverage For Autism Spectrum
Disorder Therapies
08-147
(sBH 5158)
An Act Making Changes To The
Insurance Statutes
June 11, 2008
Description
Expands the benefits payable under a group
health insurance policy for treatment
received in a residential treatment facility by
(1) eliminating a three-day hospital stay
prerequisite for children and adolescents
and (2) extending the benefit to adults.
Requires benefits be paid when a physician,
psychiatrist, psychologist, or clinical social
worker assesses the person and determines
that he or she cannot appropriately, safely,
or effectively be treated in other settings.
Requires coverage for physical, speech, and
occupational therapy services for the
treatment of autism spectrum disorders to
the extent such services are a covered
benefit for other diseases and conditions
under the policy.
Revises the criteria for determining when a
child loses coverage to when the child
marries; ends his or her Connecticut
residency, unless he or she is (a) under age
19 or (b) a full-time student at an accredited
school of higher education; becomes covered
under a group health plan through his or
her employment; or turns age 26.
Page 6 of 18
2008-R-0326
CONNECTICUT’S HEALTH INSURANCE MANDATES
Table 5: Connecticut Health Insurance Mandates: Required Benefits
CGS §
Mandate
Applicable to Group
Policy, Individual
Policy, or Both
Description
38a-476(b)(1) Preexisting
Condition
Coverage
Group
May not impose preexisting condition
exclusion beyond 12 months after effective
date of coverage, and exclusion may only
relate to conditions for which medical advice,
diagnosis, care, or treatment was
recommended or received six months before
the policy’s effective date.
38a-476(b)(2) Preexisting
Condition
Coverage
Individual, except for
short-term policy
May not impose preexisting condition
exclusion beyond 12 months after effective
date of coverage, and exclusion may only
relate to conditions for which medical advice,
diagnosis, care, or treatment was
recommended or received 12 months before
the policy’s effective date.
38a-476(g)
Preexisting
Condition
Coverage
Individual short-term
policy
May not impose preexisting condition
exclusion beyond 12 months after effective
date of coverage, and exclusion may only
relate to conditions for which medical advice,
diagnosis, care, or treatment was
recommended or received 24 months before
the policy’s effective date.
38a-476b
Availability of
Psychotropic
Drugs
Both
No mental health care benefit provided
under state law, or with state funds or to
state employees may limit the availability of
the most effective psychotropic drugs.
38a-482a
38a-513c
Medically
Necessary
Definition
Both
Specifies the definition of “medically
necessary” that policies must include.
38a-483c
38a-513b
Experimental
Treatments
Both
Procedures, treatments, or drugs that have
completed a Phase III FDA clinical trial.
Appeals process expedited for those with a
life expectancy of less than two years.
38a-488a
38a-514
Mental Illness
Parity
Both
Diagnosis and treatment of mental or
nervous conditions. Coverage cannot differ
from the terms, conditions, or benefits for
the diagnosis or treatment of medical,
surgical, or other physical health conditions.
June 11, 2008
Page 7 of 18
2008-R-0326
Table 5:-ContinuedCGS §
Mandate
Applicable to Group
Policy, Individual
Policy, or Both
Description
Benefits for residential treatment facility for
a person with a serious mental illness are
payable when the person has been confined
in a hospital for such illness for at least
three days immediately preceding
confinement in the residential treatment
facility and the illness would otherwise
necessitate continued hospital confinement
if such care and treatment were not
available through a residential treatment
center for children and adolescents.
38a-488a
Residential
Treatment
Facilities
Individual
38a-514
Residential
Treatment
Facilities
Group
(PA 08-125)
38a-489
38a-515
Mentally or
Physically
Handicapped
Dependent
Children
Effective January 1, 2009:
Benefits for residential treatment facility for
a person with a serious mental of nervous
condition are payable when a physician,
psychiatrist, psychologist, or clinical social
worker assesses the person and determines
that he or she cannot appropriately, safely,
or effectively be treated in other settings.
Both
After passing dependent status and coverage
would otherwise end, coverage must
continue if child is both mentally or
physically handicapped and dependent upon
insured for support.
38a-490
Newborns and
38a-508
Adopted
38a-516 38a- Children
549
Both
Injury and sickness, including care and
treatment of congenital defects and birth
abnormalities, for newborns from birth and
for adopted children from legal placement for
adoption.
38a-490a
38a-516a
Birth-to-Three
Both
At least $3,200 per child annually for
medically necessary early invention services,
up to $9,600 per child over three years.
38a-490b
38a-516b
Hearing Aids
for Children
Both
Hearing aids for children 12 and under.
Coverage may be limited to $1,000 within a
24-month period.
38a-490c
38a-516c
Craniofacial
Disorders
Both
Medically necessary orthodontic processes
and appliances for treatment of craniofacial
disorders for people under age 18. Coverage
is not required for cosmetic surgery.
June 11, 2008
Page 8 of 18
2008-R-0326
Table 5: -ContinuedCGS §
Mandate
Applicable to Group
Policy, Individual
Policy, or Both
Description
38a-492l
38a-516d
Children with
Cancer
Both
Coverage for children diagnosed with cancer
after December 31, 1999 for
neuropsychological testing a physician
orders to assess the extent chemotherapy or
radiation treatment has caused the child to
have cognitive or developmental delays.
Insurers cannot require pre-authorization for
the tests.
38a-491a
38a-517a
Anesthesia for
Dental Services
Both
Medically necessary general anesthesia,
nursing, and related hospital services for inpatient, outpatient, or one-day dental
services.
38a-492
38a-518
Accidental
Ingestion or
Consumption of
Controlled
Drugs
Both
Emergency medical care for the accidental
ingestion or consumption of controlled
drugs. Coverage is subject to a minimum of
30 days inpatient care and a maximum $500
for outpatient care per calendar year.
38a-492a
38a-518a
Hypodermic
Needles and
Syringes
Both
Hypodermic needles and syringes prescribed
by a prescribing practitioner for
administering medications.
38a-492b
38a-518b
Off-Label
Cancer Drugs
Both
If a prescription drug is recognized for
treatment of a specific type of cancer, a
policy cannot exclude coverage of the drug
when it is used for another type of cancer.
38a-492c
38a-518c
Protein
Modified Food
and Specialized
Formula
Both
Amino acid modified and low protein
modified food products when prescribed for
the treatment of inherited metabolic diseases
and cystic fibrosis. Medically necessary
specialized formula for children up to age
12. Food and formula must be administered
under the direction of a physician. Coverage
for preparations, food products, and
formulas must be on the same basis as
coverage outpatient prescription drugs.
38a-492d
38a-518d
Diabetes
Both
Laboratory and diagnostic tests for all types
of diabetes. Medically necessary equipment,
drugs, and supplies for insulin-dependent,
insulin using, gestational, and non-insulin
using diabetes.
38a-492e
38a-518e
Diabetes SelfManagement
Training
Both
Outpatient self-management training
prescribed by a licensed health care
professional. Coverage is subject to the same
terms and conditions as other policy
benefits.
June 11, 2008
Page 9 of 18
2008-R-0326
Table 5:-ContinuedCGS §
Mandate
Applicable to Group
Policy, Individual
Policy, or Both
Description
38a-492f
38a-518f
Prescription
Drugs Removed
from Formulary
Both
A prescription drug that has been removed
from the list of covered drugs must be
continued if the insured was previously
using the drug for the treatment of a chronic
illness and it is deemed medically necessary.
38a-492g
38a-518g
Prostate
Screening
Both
Laboratory and diagnostic tests to screen for
prostate cancer for men who are
symptomatic, have a family history, or are
over 50.
38a-492h
38a-518h
Lyme Disease
Treatment
Both
Lyme disease treatment including not less
that 30 days of intravenous antibiotic
therapy, 60 days of oral antibiotic therapy,
or both, and further treatment if
recommended by a rheumatologist,
infectious disease specialist, or neurologist.
38a-492i
38a-518i
Pain
Management
Both
Access to a pain management specialist and
coverage for pain treatment ordered by such
specialist.
38a-492j
38a-518j
Ostomy
Appliances and
Supplies
Both
If policy covers ostomy surgery, policy must
also cover up to $1000 per year for medically
necessary ostomy-related appliances and
supplies.
38a-492k
38a-518k
Colorectal
Cancer
Screening
Both
Colorectal cancer screening. Frequency of
screening to be based on recommendations
by the American College of Gastroenterology.
38a-493
38a-520
Home Health
Care
Both
Home health care including (1) part-time or
intermittent nursing care and home health
aide services; (2) physical, occupational, or
speech therapy; (3) medical supplies, drugs
and medicines; and (4) medical social
services. Coverage can be limited to no less
than 80 visits per year and, for a terminally
ill person, no more than $200 for medical
social services. Coverage can be subject to
an annual deductible of no more than $50
and a coinsurance of no less than 75%,
except that a high deductible plan used to
establish a medical savings account is
exempt from the deductible limit.
June 11, 2008
Page 10 of 18
2008-R-0326
Table 5: -ContinuedCGS §
Mandate
Applicable to Group
Policy, Individual
Policy, or Both
Description
38a-523
Comprehensive
Rehabilitation
Services
Group
Group health insurance must offer coverage
for comprehensive rehabilitation services,
including (1) physician services, physical
and occupational therapy, nursing care,
psychological and audiological services, and
speech therapy; (2) social services provided
by a social worker; (3) respiratory therapy;
(4) prescription drugs and medicines; (5)
prosthetic and orthotic devices and; (6) other
supplies and services prescribed by a doctor.
38a-496
38a-524
Occupational
Therapy
Both
If policy covers physical therapy, it must
provide coverage for occupational therapy.
38a-482
38a-497
38a-554
Dependent
Children
Both
Until January 1, 2009:
38a-482
38a-497
Children
Unmarried, dependent child under age 19,
or age 23 if a full-time student at an
accredited school.
Individual
Coverage continues until the policy's
anniversary date on or after the date the
child marries; ends his or her Connecticut
residency, unless he or she is (a) under age
19 or (b) a full-time student at an accredited
school of higher education; becomes covered
under a group health plan through his or
her employment; or attains age 26.
(PA 08-147, §
8)
38a-554
Effective January 1, 2009:
Children
Group
Unmarried child under age 26. Must offer
continuation coverage to the end of the
month in which the child marries; ends his
or her Connecticut residency, unless he or
she is (a) under age 19 or (b) a full-time
student at an accredited school of higher
education; becomes covered under a group
health plan through his or her employment;
or attains age 26.
(PA 08-147, §
9)
38a-498
38a-525
Ambulance
Services
Both
Ambulance service when medically
necessary. Payment must be on a direct pay
basis where notice of assignment is reflected
on the bill.
38a-498a
38a-525a
911 Calls
Both
Cannot require preauthorization for 911
calls.
June 11, 2008
Page 11 of 18
2008-R-0326
Table 5: -ContinuedCGS §
Mandate
Applicable to Group
Policy, Individual
Policy, or Both
Description
38a-498b
38a-525b
Mobile Field
Hospitals
Both
Benefits for isolation care and emergency
services provided by mobile field hospitals,
previously called critical access hospitals.
Such benefits are subject to any policy
provisions that apply to other covered
services. The rates a policy pays must be
equal to the rates Medicaid pays, as
determined by the Department of Social
Services.
38a-498c
38a-525c
Injured and
Under the
Influence
Both
Insurance polices prohibited from denying
coverage for health care services rendered to
an injured insured person if the injury is
alleged to have occurred or occurs when the
person has an elevated blood alcohol level
(0.08% or more) or is under the influence of
drugs or alcohol.
38a-501
Long-Term
Care Policy –
Non-Forfeiture
Individual
Prohibits an insurer from issuing or
delivering a long-term care policy on or after
July 1, 2008 unless it had offered the
prospective insured an optional nonforfeiture benefit during the policy
solicitation or application process. If the
non-forfeiture option is declined, the insurer
must give the insured a contingent benefit
upon lapse.
38a-501
Long-Term
Care Policy –
Elimination
Period
Individual
Changes the elimination period required
under a long-term care insurance policy.
Prior law required a “reasonable” elimination
period (i.e., a waiting period after the onset
of the injury, illness, or function loss during
which no benefits are payable). The act
instead requires an elimination period that
is (1) up to 100 days of confinement or (2)
between 100 days and two years of
confinement if an irrevocable trust is in
place that is estimated to be sufficient to
cover the person's confinement costs during
this period. Sets requirements for the trust.
38a-502
38a-529
Veteran’s Home
and Hospital
June 11, 2008
Both
Page 12 of 18
Cannot exclude coverage for services
provided by the Veteran’s Home and
Hospital.
2008-R-0326
Table 5: -ContinuedCGS §
Mandate
Applicable to Group
Policy, Individual
Policy, or Both
Description
38a-503
38a-530
Mammography
and Breast
Cancer
Screening
Both
Baseline mammogram for woman 35 to 39
and one every year for woman 40 and older.
Additional coverage must be provided for a
comprehensive ultrasound screening of a
woman’s entire breast(s) if (1) a mammogram
shows heterogeneous or dense breast tissue
based on BI-RADS or (2) she is at increased
breast cancer risk because of family history,
her prior history, genetic testing, or other
indications determined by her physician or
advanced-practice nurse. Coverage is
subject to any policy provisions applicable to
other covered services.
38a-503b
38a-530b
ObstetricianGynecologist;
Pap Smear
Both
Direct access to participating in-network obgyn for gynecological examination, care
related to pregnancy, and primary and
preventive obstetric and gynecologic services
required as result of a gynecological
examination or condition (includes pap
smear). Female enrollees may also designate
participating ob-gyn or other doctor as
primary care provider.
38a-503c
38a-530c
Maternity Care
Both
Minimum 48-hour hospital stay for mother
and newborn after vaginal delivery and
minimum 96-hour hospital stay after
caesarian delivery.
38a-503d
38a-530d
Mastectomy
Both
Minimum 48-hour hospital stay after
mastectomy or lymph node dissection or
longer stay if recommended by physician.
38a-503e
38a-530e
Contraceptives
Both
If prescription drugs are covered, then
prescription contraceptives must be covered.
An employer or individual may decline
contraceptive coverage if it conflicts with
religious beliefs.
38a-533
Treatment of
Alcoholism
Group
Expenses incurred in connection with
medical complications of alcoholism such as
cirrhosis of the liver, gastrointestinal
bleeding, pneumonia, and delirium tremens.
38a-507
38a-534
Chiropractic
Services
Both
Cover chiropractor services to same extent
as coverage for a physician.
38a-535
Preventive
Pediatric Care
Group
Preventive pediatric care at the following
intervals (1) every 2 months from birth to 6
months, (2) every 3 months from 9 to 18
months, and (3) annually from 2 to 6 years
of age. Coverage is subject to any policy
provisions that apply to other services
covered under the policy.
June 11, 2008
Page 13 of 18
2008-R-0326
Table 5: -ContinuedCGS §
38a-535
Mandate
Applicable to Group
Policy, Individual
Policy, or Both
Lead Screening
Both
Description
Effective January 1, 2009:
Coverage for blood lead screening and risk
assessments ordered by primary care
providers in accordance with § 48 of PA 072, JSS.
38a-509
38a-536
Infertility
38a542(a)&(b)
Breast Implant
Removal
Group
38a504(a)&(b)
38a542(a)&(b)
Treatment for
Leukemia,
Tumors, and
Wigs for
Chemotherapy
Patients
Both
Surgical removal of tumors an treatment of
leukemia, including outpatient
chemotherapy, reconstructive surgery, nondental prosthesis, surgical removal of
breasts due to tumors, and a wig if
prescribed by a licensed oncologist for a
patient suffering hair loss due to
chemotherapy. Annual coverage must be at
least $500 for surgical tumor removal, $500
for reconstructive surgery, $500 for
outpatient chemotherapy, $350 for a wig,
and $300 for prosthesis, except for surgical
removal of breasts due to tumors, the
prosthesis benefit must be at least $300 for
each breast removed.
38a-504(c)
38a-542(c)
Breast
Reconstruction
after
Mastectomy
Both
Reconstructive surgery on non-diseased
breast for symmetrical appearance. Coverage
is subject to the same terms and conditions
as other benefits under the policy.
38a-504a –
38a-504g;
38a-542a –
38a-542g
Cancer Clinical
Trials
Both
Routine patient costs relating to cancer
clinical trials. Out-of-network hospitalization
paid as in-network benefit if services are not
available in-network. Such trials must have
peer-reviewed protocols approved by one of
several federal organizations.
June 11, 2008
Both
Page 14 of 18
Medically necessary costs of diagnosing and
treating infertility.
Medically necessary removal of breast
implants implanted on or before July 1,
1994. Annual coverage must be at least
$1,000 for removal of any such breast
implant.
2008-R-0326
Table 5: -ContinuedCGS §
Mandate
Applicable to Group
Policy, Individual
Policy, or Both
Description
38a-511
38a-550
Copays for
Imaging
Services (MRIs,
CAT scans, and
PET scans)
Both
Limits copays for MRIs and CAT scans to no
more than (1) $375 for all such services
annually and (2) $75 for each one. Limits
copays for PET scans to no more than (1)
$400 for all such scans annually and (2)
$100 for each one. Limits not applicable if
(1) the ordering physician performs the
service or is in the same practice group as
the one who does and (2) to high deductible
health plans designed to compatible with
federally qualified Health Savings Accounts.
PA 08-132
Autism
Spectrum
Disorder
Therapies
Both
Effective January 1, 2009:
Requires coverage for physical, speech, and
occupational therapy services for the
treatment of autism spectrum disorders to
the extent such services are a covered
benefit for other diseases and conditions
under the policy.
Table 6: Connecticut Health Insurance Mandates: Covered Providers
CGS §
38a-488a
38a-514
38a-491
38a-517
38a-492i
38a-518i
38a-496
38a-524
38a-499
38a-526











Provider
Licensed physician
Licensed psychiatrist
Licensed psychologist
Licensed clinical social worker
Independent social worker certified before October 1, 1990
Licensed marital and family therapist
Marital and family therapist certified before October 1, 1992
Licensed alcohol and drug counselor
Certified alcohol and drug counselor
Licensed professional counselor
Licensed dentist

Pain management specialist

(i.e., a physician credentialed by the American Academy of
Pain Management or who is a board-certified anesthesiologist,
neurologist, oncologist, or radiation oncologist with additional
training in pain management)
Licensed occupational therapist




Licensed physician assistant
Certified nurse practitioner
Certified psychiatric-mental health clinical nurse specialist
Certified nurse mid-wife
June 11, 2008
Page 15 of 18
2008-R-0326
Table 6: -ContinuedCGS §
38a-503b
38a-530b
38a-507
38a-534
38a-523
Provider




Comprehensive rehabilitation services provided by:









38a-553
Obstetrician-gynecologist
Nurse mid-wife
Advanced practice nurse
Licensed chiropractor
Physician
Physical therapist
Occupational therapist
Nurse
Psychologist
Audiologist
Speech therapist
Social workers
Respiratory therapist
(Optional group health insurance benefit insurer must offer.)
 Physician
 Registered nurse
 Social worker
 Licensed physical therapist
Table 7: Connecticut Health Insurance Mandates: Covered Facilities
CGS §
38a-488a
38a-514
38a-498b
38a-525b
38a-502
38a-529
38a-523
38a-553







Facility
Licensed hospital or clinic
Child guidance clinic
Residential treatment facility
Nonprofit community mental health center
Nonprofit licensed adult psychiatric clinic
State mobile field hospital (formerly known as critical access
hospitals)
State Veterans’ Home
 Comprehensive rehabilitation facility
(Optional group health insurance benefit insurer must offer.
 Hospital
 Skilled nursing facility
 Licensed alcohol treatment facility
June 11, 2008
Page 16 of 18
2008-R-0326
MEDICARE PARTS A AND B
Table 8 shows many of the services Medicare covers. Coverage may
be subject to certain conditions and limitations, including patient
copayments and coinsurance. For more information regarding these
conditions and limitations, refer to the enclosed federal government
publication regarding Medicare, which may be viewed online at:
http://www.medicare.gov/Publications/Pubs/pdf/10116.pdf.
Table 8: What “Original” Medicare Covers
Preventive Services (Part B coverage):
Abdominal aortic aneuryism screening
Bone mass measurement
Cardiovascular screening
Colorectal cancer screening
Diabetes screening
Diabetes self-management training
Flu shot
Glaucoma tests
Hepatitis B shot
Mammograms
Medical nutrition therapy services
Pap test/pelvic exam (cancer screening)
Physical exam (one “Welcome to Medicare” exam only)
Pneumococcal shot
Prostate cancer screening
Smoking cessation counseling
Part A (Hospital Insurance):
Anesthesia
Blood
Chemotherapy
Clinical research study costs
Defibrillator (implantable automatic)
Dental services (not routine care)
Dialysis (kidney) treatment
Home health services
Hospice care
Hospital care
Mental health and substance abuse care
Radiation therapy
Religious nonmedical health care institution
Respite care
Skilled nursing facility care
Transplants (facility charges)
Part B (Medical Insurance):
Ambulance services
Ambulatory surgical centers
Anesthesia
Blood
Breast reconstruction and protheses after mastectomy
(including post-surgical brassiere)
Canes/crutches
June 11, 2008
Page 17 of 18
2008-R-0326
Table 8: -ContinuedPart B (Medical Insurance):
Cardiac rehabilitation
Chemotherapy
Chiropractic services
Clinical research study costs
Commode chairs
Defibrillator (implantable automatic)
Diabetes supplies and services
Diagnostic tests, X-rays, and clinical laboratory services
Dialysis services and supplies
Doctor’s services
Durable medical equipment
Emergency room services
Foot care and podiatrist services (not routine care)
Home health services
Hospital services (outpatient)
Laboratory services
Macular degeneration treatment
Mental health and substance abuse care
Orthotics (artificial limbs and eyes and arm, leg, back, and
neck braces)
Ostomy supplies
Oxygen therapy
Physical and occupational therapy
Speech-language pathology services
Practitioner services
(clinical social workers, physician assistants, and nurse
practitioner)
Prescription drugs (limited benefit)
Preventive services (see above)
Radiation therapy
Rural health clinic and federally-qualified health center
services
Second surgical opinions
Surgical dressing services
Telemedicine (rural areas)
Transplants (doctor services)
JLK:ts
June 11, 2008
Page 18 of 18
2008-R-0326