General Assembly Raised Bill No. 926
January Session, 2017 LCO No. 4370
*04370_______INS*
Referred to Committee on INSURANCE AND REAL ESTATE
Introduced by:
(INS)
General Assembly
Raised Bill No. 926
January Session, 2017
LCO No. 4370
*04370_______INS*
Referred to Committee on INSURANCE AND REAL ESTATE
Introduced by:
(INS)
AN ACT CONCERNING STOP-LOSS INSURANCE POLICIES FOR HEALTH CARE OR MEDICAL BENEFITS.
Be it enacted by the Senate and House of Representatives in General Assembly convened:
Section 1. (NEW) (Effective January 1, 2018) (a) For the purposes of this section:
(1) "Actuarial certification" means a written statement by a member of the American Academy of Actuaries or other individual acceptable to the commissioner that the member or individual has (A) examined an insurance company's books, records, procedures and practices concerning, at a minimum, the company's actuarial assumptions and methods used to establish attachment points and other terms of a stop-loss insurance policy for health care or medical benefits, and (B) determined, on the basis of such examination, that the company is in compliance with this section and all regulations adopted under subsection (f) of this section;
(2) "Affordable Care Act" has the same meaning as provided in section 38a-1080 of the general statutes;
(3) "Attachment point" means the dollar value of claims incurred by an insured at which the insurance company that issued the stop-loss insurance policy for health care or medical benefits to the insured incurs liability for payment;
(4) "Covered individual" means an individual who is insured under an individual or group health insurance policy or enrolled in a medical benefits plan;
(5) "Expected claims" means the total dollar value of claims that, in the absence of a stop-loss insurance policy for health care or medical benefits or other insurance coverage, is projected to be incurred by an insured under its health insurance policy or medical benefits plan;
(6) "Insured" means a person insured by a stop-loss insurance policy for health care or medical benefits;
(7) "Large employer" has the same meaning as provided in section 1304 of the Affordable Care Act, as amended from time to time; and
(8) "Small employer" has the same meaning as provided in section 1304 of the Affordable Care Act, as amended from time to time.
(b) On and after January 1, 2018, no insurance company shall deliver, issue for delivery, renew, amend or continue in this state a stop-loss insurance policy for health care or medical benefits that: (1) Has an annual attachment point for claims incurred per covered individual that is less than twenty thousand dollars; (2) for a small employer, has an annual aggregate attachment point that is less than twenty thousand dollars, four thousand dollars multiplied by the number of covered individuals or one hundred twenty per cent of expected claims, whichever is greater; (3) for a large employer, has an annual aggregate attachment point that is less than one hundred ten per cent of expected claims; or (4) provides direct coverage for the health care or medical expenses of an individual.
(c) If an insurance company delivers, issues for delivery, renews, amends or continues an employer's stop-loss insurance policy for health care or medical benefits in this state that satisfies subsection (b) of this section, such insurance company shall determine at least annually the number of such employer's employees.
(d) Not later than March fifteenth annually, each insurance company that delivers, issues for delivery, renews, amends or continues an employer's stop-loss insurance policy for health care or medical benefits in this state that satisfies subsection (b) of this section shall submit to the Insurance Commissioner an actuarial certification. Each company shall maintain a copy of the certification at its principal place of business.
(e) The commissioner shall not deny approval of a stop-loss insurance policy for health care or medical benefits on the grounds that the policy contains one or more of the following provisions that is in conflict with a provision of the insured's underlying health insurance policy or medical benefits plan: A provision concerning (1) medical necessity, (2) the usual and customary standard of care, (3) an experimental or investigational treatment, (4) mandatory case management services, (5) an annual limit on the dollar value of a specific benefit or all benefits provided to a covered individual, (6) a mandatory provider network, (7) a financial incentive for a covered individual to use a provider network; (8) an insurance company's right to examine the person of a covered individual, or (9) the ability of an insurance company to deem any covered individual's claim to be ineligible for coverage because the covered individual was not actively at work.
(f) The commissioner shall adopt regulations, in accordance with chapter 54 of the general statutes, to implement this section.
Sec. 2. Section 38a-8b of the general statutes is repealed and the following is substituted in lieu thereof (Effective January 1, 2018):
No [stop loss] stop-loss policy may be issued or delivered in this state unless a copy of the [stop loss] stop-loss policy form has been submitted to, and approved by, the Insurance Commissioner pursuant to regulations that the commissioner may adopt in accordance with chapter 54. [Such regulations, if adopted, shall include, but need not be limited to, a definition of a stop loss policy and the standards for filing and review of stop loss policies.]
This act shall take effect as follows and shall amend the following sections:
Section 1 January 1, 2018 New section
Sec. 2 January 1, 2018 38a-8b
This act shall take effect as follows and shall amend the following sections:
Section 1
January 1, 2018
New section
Sec. 2
January 1, 2018
38a-8b
Statement of Purpose:
To specify the required and prohibited terms of stop-loss insurance policies for health care or medical benefits, establish criteria for the Insurance Commissioner's review of such policies and limit the scope of the commissioner's regulatory authority over such policies.
[Proposed deletions are enclosed in brackets. Proposed additions are indicated by underline, except that when the entire text of a bill or resolution or a section of a bill or resolution is new, it is not underlined.]