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General Assembly Substitute Bill No. 6710
January Session, 2023
AN ACT CONCERNING ASSOCIATION HEALTH PLANS AND
ESTABLISHING A TASK FORCE TO STUDY STOP -LOSS
INSURANCE.
Be it enacted by the Senate and House of Representatives in General
Assembly convened:
Section 1. (NEW) (Effective October 1, 2023) For the purposes of this 1
section and sections 2, 3 and 5 of this act: 2
(1) "Commissioner" means the Insurance Commissioner; 3
(2) "Employer member" means an entity in this state that is part of a 4
sponsoring association, conducts business in this state and employs 5
individuals in this state; 6
(3) "ERISA" means the Employee Retirement Income Security Act of 7
1974, as amended from time to time; 8
(4) "Fully insured multiple employer welfare arrangement" means 9
any health benefit plan offered by a sponsoring association for the 10
purpose of providing insurance to participating employees of a 11
sponsoring association that is funded through a policy of insurance 12
issued by a licensed insurance company in this state; 13
(5) "Health enhancement program" means any health benefit 14
program that ensures access and removes barriers to essential, high-15 Substitute Bill No. 6710
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value clinical services; 16
(6) "Preexisting conditions provision" has the same meaning as 17
provided in section 38a-476 of the general statutes; 18
(7) "Self-funded multiple employer welfare arrangement" means any 19
health benefit plan offered by a sponsoring association, that is not fully 20
insured by a licensed insurance company in this state, for the purpose 21
of providing insurance to participating employer members of a 22
sponsoring association; 23
(8) "Sponsoring association" means any industry trade group or any 24
other trade group with employer members representing multiple trades 25
incorporated in this state that (A) is organized and has a written 26
constitution or bylaws, (B) has not less than fifty employer members, 27
and (C) has been maintained in good faith for not less than the 28
immediately preceding five years for purposes other than obtaining or 29
providing insurance; and 30
(9) "Value-based insurance design" means any material term in a 31
health insurance policy that is designed to increase the quality of 32
covered benefits or health care services while reducing the cost of such 33
policy, benefits or health care services. 34
Sec. 2. (NEW) (Effective October 1, 2023) (a) No self-funded multiple 35
employer welfare arrangement shall issue any health benefit plan in this 36
state unless such self-funded multiple employer welfare arrangement 37
first obtains a license from the commissioner. 38
(b) Any health benefit plan issued by a self-funded multiple 39
employer welfare arrangement that covers one or more employees of 40
one or more participating employer members of a sponsoring 41
association shall: 42
(1) Provide coverage for (A) essential health benefits as defined in the 43
Patient Protection and Affordable Care Act, P.L. 111-148, as amended 44
from time to time, or regulations adopted thereunder, and (B) the state 45 Substitute Bill No. 6710
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mandated coverage requirements under chapter 700c of the general 46
statutes; 47
(2) Offer a minimum level of coverage designed to provide health 48
benefits that are actuarially equivalent to not less than sixty per cent of 49
the full actuarial value of the benefits provided under the health benefit 50
plan and include coverage for inpatient hospital services and physician 51
services; 52
(3) Not limit or exclude coverage for any individual by imposing any 53
preexisting conditions provision on such individual; 54
(4) Not establish discriminatory rules based on the health status of an 55
individual related to health benefit plan eligibility, or premium or 56
contribution requirements; 57
(5) Establish base rates formed on an actuarially sound, modified 58
community rating methodology that considers the pooling of all 59
participants' claims; 60
(6) Utilize each employer member's risk profile to determine 61
premiums by actuarially adjusting above or below established base 62
rates, and utilize pooling or reinsurance of individual large claimants to 63
reduce the adverse impact on any specific employer member's 64
premiums; 65
(7) Make any health benefit plan available to all employer members 66
of a sponsoring association regardless of any factor relating to the health 67
status of such employer members or individuals eligible for coverage 68
through any employer member; 69
(8) Implement value-based insurance design and value-based 70
contracting by administering programs, which may include, but are not 71
limited to, centers of excellence, wellness programs, health 72
enhancement programs, alternative payment models, chronic disease 73
navigation, patient-centered medical homes and advanced primary 74
care; and 75 Substitute Bill No. 6710
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(9) Comply with the notification requirements to covered persons set 76
forth in sections 38a-591d, 38a-591e and 38a-591f of the general statutes 77
with respect to utilization review and benefit determinations of a benefit 78
request or claim. 79
(c) Any sponsoring association shall form a trust that shall establish 80
and maintain any health benefit plans for such sponsoring association. 81
Such trust shall be authorized to sell health benefit plans to employer 82
members of the sponsoring association by meeting the following 83
conditions: 84
(1) The trust shall be subject to ERISA and any regulations or 85
standards prescribed by the United States Department of Labor to 86
enforce multiple employer welfare arrangements; 87
(2) A Form M-1 shall be filed each year with the United States 88
Department of Labor. For purposes of this subdivision, "Form M-1" 89
means an annual report required by the United States Department of 90
Labor for multiple employer welfare arrangements that includes, but is 91
not limited to, the following: (A) Identification of the sponsoring 92
association and trust establishing a self-funded multiple employer 93
welfare arrangement; and (B) a description of any health benefit plans 94
offered through the trust as a self-funded multiple employer welfare 95
arrangement; 96
(3) Any organizational documents for a trust shall: 97
(A) State that such trust is sponsored by the sponsoring association; 98
(B) State that the purpose of such trust is to provide health care 99
benefits, including, but not limited to, medical, prescription drug, dental 100
and vision benefits, to participating employees of the sponsoring 101
association or its members, and the dependents of such participating 102
employees or members, through health benefit plans; 103
(C) Provide that trust funds shall be used for the benefit of 104
participating employees of the sponsoring association and the 105 Substitute Bill No. 6710
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dependents of such participating employees, through (i) self-funding of 106
claims or the purchase of reinsurance, or any combination thereof, and 107
(ii) defraying the costs and expenses of administering and operating 108
such trust and any health benefit plan; 109
(D) Limit participation in any health benefit plan to participating 110
employees of the sponsoring association and such sponsoring 111
association's employer members; 112
(E) Establish and maintain a board of trustees, composed of not less 113
than five trustees, that shall have fiscal control over such self-funded 114
multiple employer welfare arrangement. Any board of trustees shall 115
have the authority to (i) approve applications of association employer 116
members for participation in the self-funded multiple employer welfare 117
arrangement, and (ii) contract with any licensed administrator or service 118
company to administer the daily operations of the self-funded multiple 119
employer welfare arrangement; 120
(F) Implement a process for the election of trustees to the board of 121
trustees; and 122
(G) Require each trustee to discharge such trustee's duties in 123
accordance with generally accepted fiduciary standards, as determined 124
by the commissioner, in accordance with the provisions of chapter 54 of 125
the general statutes; 126
(4) The trust shall establish and maintain reserves calculated in 127
accordance with the accounting requirements of the National 128
Association of Insurance Commissioners Accounting Practices and 129
Procedures Manual, version effective January 1, 2001, and subsequent 130
revisions, and in accordance with any financial and solvency 131
regulations adopted by the commissioner, in accordance with the 132
provisions of chapter 54 of the general statutes; 133
(5) The trust shall purchase and maintain an insurance policy 134
providing coverage for stop-loss insurance with retention levels 135
determined in accordance with actuarial principles from insurers 136 Substitute Bill No. 6710
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licensed to transact the business of insurance in this state; 137
(6) The trust shall purchase and maintain commercially reasonable 138
fiduciary liability insurance from insurers licensed to transact the 139
business of insurance in this state; 140
(7) The trust shall purchase and maintain a bond in an amount and 141
form approved by the commissioner; and 142
(8) No trust shall include in its name, the words "insurance", 143
"insurer", "underwriter", "mutual", or any other word or term or 144
combination of words or terms that is descriptive of an insurance 145
company or insurance business, unless the context of such words or 146
terms indicate that such trust is not an insurance company and is not 147
transacting the business of insurance. 148
(d) Any board of trustees established pursuant to subsection (c) of 149
this section shall: 150
(1) Operate any health benefit plans in accordance with generally 151
accepted fiduciary standards, as established in regulations adopted by 152
the commissioner, in accordance with the provisions of chapter 54 of the 153
general statutes; and 154
(2) Have the authority to collect special assessments against employer 155
members and enforce the collection of such special assessments. 156
(e) Each employer member shall be liable for such employer 157
member's allocated share of the liabilities of the sponsoring association 158
under any health benefit plan, as determined by the board of trustees. 159
(f) Health benefit plan documents issued by any such self-funded 160
multiple employer welfare arrangement shall have the following 161
statement printed on the first page in fourteen-point boldface type: "This 162
coverage is not insurance and is not offered through an insurance 163
company. This coverage is not required to comply with certain federal 164
market requirements for health insurance, and is not required to comply 165 Substitute Bill No. 6710
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with certain state laws for health insurance. Each employer member 166
shall be liable for such employer member's allocated share of the 167
liabilities of the sponsoring association under the health benefit plans as 168
determined by the board of trustees. Each employer member may be 169
responsible for paying an additional sum if the annual premiums 170
present a deficit of funds for the trust. The trust's financial documents 171
shall be made available upon request by a participant in the health 172
benefit plan". 173
(g) This section shall not apply to any fully insured multiple 174
employer welfare arrangement that offers or provides any health benefit 175
plan that is fully insured by any insurer authorized to transact the 176
business of insurance in this state. 177
(h) The commissioner shall adopt regulations, in accordance with the 178
provisions of chapter 54 of the general statutes, to implement the 179
provisions of this section, including, but not limited to, the requirements 180
of self-funded multiple employer welfare arrangements for: (1) 181
Licensing; (2) financial condition and actuarial standards; (3) solvency 182
and insolvency, including, but not limited to, the use of trust deposits 183
and security bonds; (4) transparency and reporting; and (5) filings. 184
Sec. 3. (NEW) (Effective October 1, 2023) (a) Any sponsoring 185
association that sponsors any fully insured multiple employer welfare 186
arrangement shall have a written constitution and bylaws that require: 187
(1) The sponsoring association to hold regular meetings not less than 188
once annually to further the purposes of such sponsoring association's 189
participating employers; and 190
(2) The sponsoring association to collect dues or solicit contributions 191
from such sponsoring association's participating employers. 192
(b) Any health benefit plan issued by any fully insured multiple 193
employer welfare arrangement shall: 194
(1) Comply with regulations or standards prescribed by the United 195 Substitute Bill No. 6710
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States Department of Labor pertaining to multiple employer welfare 196
arrangements; 197
(2) Qualify as a large group market plan subject to (A) all coverage 198
mandates under chapter 700c of the general statutes applicable to a large 199
group market plan offered in this state, and (B) the large group market 200
insurance regulations pursuant to the Public Health Service Act, 42 USC 201
2791, as amended from time to time; 202
(3) Adhere to the group health plan coverage requirements under the 203
Patient Protection and Affordable Care Act, P.L. 111-148, as amended 204
from time to time; 205
(4) Not limit or exclude coverage for any individual by imposing any 206
preexisting conditions provision on such individual; 207
(5) Provide coverage for (A) essential health benefits as defined in the 208
Patient Protection and Affordable Care Act, P.L. 111-148, as amended 209
from time to time, or regulations adopted thereunder, and (B) the state 210
mandated coverage requirements under chapter 700c of the general 211
statutes; 212
(6) Offer a minimum level of coverage designed to provide benefits 213
that are actuarially equivalent to not less than sixty per cent of the full 214
actuarial value of the benefits provided under the health benefit plan; 215
and 216
(7) Be available only to participating employers of the fully insured 217
multiple employer welfare arrangement. 218
Sec. 4. Section 38a-567 of the general statutes is repealed and the 219
following is substituted in lieu thereof (Effective October 1, 2023): 220
Health insurance plans [, associations of small employers] and other 221
insurance arrangements covering small employers and insurers and 222
producers marketing such plans and arrangements shall be subject to 223
the following provisions: 224 Substitute Bill No. 6710
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(1) (A) Any such plan or arrangement shall be offered on a 225
guaranteed issue basis with respect to all eligible employees or 226
dependents of such employees, at the option of the small employer, 227
policyholder or contractholder, as the case may be. 228
(B) Any such plan or arrangement shall be renewable with respect to 229
all eligible employees or dependents at the option of the small employer, 230
policyholder or contractholder, as the case may be, except: (i) For 231
nonpayment of the required premiums by the small employer, 232
policyholder or contractholder; (ii) for fraud or misrepresentation of the 233
small employer, policyholder or contractholder or, with respect to 234
coverage of individual insured, the insureds or their representatives; 235
(iii) for noncompliance with plan or arrangement provisions; (iv) when 236
the number of insureds covered under the plan or arrangement is less 237
than the number of insureds or percentage of insureds required by 238
participation requirements under the plan or arrangement; or (v) when 239
the small employer, policyholder or contractholder is no longer actively 240
engaged in the business in which it was engaged on the effective date of 241
the plan or arrangement. 242
(C) Renewability of coverage may be effected by either continuing in 243
effect a plan or arrangement covering a small employer or by 244
substituting upon renewal for the prior plan or arrangement the plan or 245
arrangement then offered by the carrier that most closely corresponds 246
to the prior plan or arrangement and is available to other small 247
employers. Such substitution shall only be made under conditions 248
approved by the commissioner. A carrier may substitute a plan or 249
arrangement as set forth in this subparagraph only if the carrier effects 250
the same substitution upon renewal for all small employers previously 251
covered under the particular plan or arrangement, unless otherwise 252
approved by the commissioner. The substitute plan or arrangement 253
shall be subject to the rating restrictions specified in this section on the 254
same basis as if no substitution had occurred, except for an adjustment 255
based on coverage differences. 256
(D) Any such plan or arrangement shall provide special enrollment 257 Substitute Bill No. 6710
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periods (i) to all eligible employees or dependents as set forth in 45 CFR 258
147.104, as amended from time to time, and (ii) for coverage under such 259
plan or arrangement ordered by a court for a spouse or minor child of 260
an eligible employee where request for enrollment is made not later than 261
thirty days after the issuance of such court order. 262
(2) (A) As used in this subdivision, "grandfathered plan" has the same 263
meaning as "grandfathered health plan" as provided in the Patient 264
Protection and Affordable Care Act, P.L. 111-148, as amended from time 265
to time. 266
(B) With respect to grandfathered plans issued to small employers, 267
the premium rates charged or offered shall be established on the basis 268
of a single pool of all grandfathered plans, adjusted to reflect one or 269
more of the following classifications: 270
(i) Age, provided age brackets of less than five years shall not be 271
utilized; 272
(ii) Gender; 273
(iii) Geographic area, provided an area smaller than a county shall 274
not be utilized; 275
(iv) Industry, provided the rate factor associated with any industry 276
classification shall not vary from the arithmetic average of the highest 277
and lowest rate factors associated with all industry classifications by 278
greater than fifteen per cent of such average, and provided further, the 279
rate factors associated with any industry shall not be increased by more 280
than five per cent per year; 281
(v) Group size, provided the highest rate factor associated with group 282
size shall not vary from the lowest rate factor associated with group size 283
by a ratio of greater than 1.25 to 1.0; 284
(vi) Administrative cost savings resulting from the administration of 285
an association group plan or a plan written pursuant to section 5-259, 286 Substitute Bill No. 6710
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provided the savings reflect a reduction to the small employer carrier's 287
overall retention that is measurable and specifically realized on items 288
such as marketing, billing or claims paying functions taken on directly 289
by the plan administrator or association, except that such savings may 290
not reflect a reduction realized on commissions; 291
(vii) Savings resulting from a reduction in the profit of a carrier that 292
writes small business plans or arrangements for an association group 293
plan or a plan written pursuant to section 5-259, provided any loss in 294
overall revenue due to a reduction in profit is not shifted to other small 295
employers; and 296
(viii) Family composition, provided the small employer carrier shall 297
utilize only one or more of the following billing classifications: (I) 298
Employee; (II) employee plus family; (III) employee and spouse; (IV) 299
employee and child; (V) employee plus one dependent; and (VI) 300
employee plus two or more dependents. 301
(C) (i) With respect to nongrandfathered plans issued to small 302
employers, the premium rates charged or offered shall be established on 303
the basis of a single pool of all nongrandfathered plans, adjusted to 304
reflect one or more of the following classifications: 305
(I) Age, in accordance with a uniform age rating curve established by 306
the commissioner; or 307
(II) Geographic area, as defined by the commissioner. 308
(ii) Total premium rates for family coverage for nongrandfathered 309
plans shall be determined by adding the premiums for each individual 310
family member, except that with respect to family members under 311
twenty-one years of age, the premiums for only the three oldest covered 312
children shall be taken into account in determining the total premium 313
rate for such family. 314
(iii) Premium rates for employees and dependents for 315
nongrandfathered plans shall be calculated for each covered individual 316 Substitute Bill No. 6710
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and premium rates for the small employer group shall be calculated by 317
totaling the premiums attributable to each covered individual. 318
(iv) Premium rates for any given plan may vary by (I) actuarially 319
justified differences in plan design, and (II) actuarially justified amounts 320
to reflect the policy's provider network and administrative expense 321
differences that can be reasonably allocated to such policy. 322
(3) No small employer carrier or producer shall, directly or indirectly, 323
engage in the following activities: 324
(A) Encouraging or directing small employers to refrain from filing 325
an application for coverage with the small employer carrier because of 326
the health status, claims experience, industry, occupation or geographic 327
location of the small employer, except the provisions of this 328
subparagraph shall not apply to information provided by a small 329
employer carrier or producer to a small employer regarding the carrier's 330
established geographic service area or a restricted network provision of 331
a small employer carrier; or 332
(B) Encouraging or directing small employers to seek coverage from 333
another carrier because of the health status, claims experience, industry, 334
occupation or geographic location of the small employer. 335
(4) No small employer carrier shall, directly or indirectly, enter into 336
any contract, agreement or arrangement with a producer that provides 337
for or results in the compensation paid to a producer for the sale of a 338
health benefit plan to be varied because of the health status, claims 339
experience, industry, occupation or geographic area of the small 340
employer. A small employer carrier shall provide reasonable 341
compensation, as provided under the plan of operation of the program, 342
to a producer, if any, for the sale of a health care plan. No small 343
employer carrier shall terminate, fail to renew or limit its contract or 344
agreement of representation with a producer for any reason related to 345
the health status, claims experience, occupation, or geographic location 346
of the small employers placed by the producer with the small employer 347 Substitute Bill No. 6710
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carrier. 348
(5) No small employer carrier or producer shall induce or otherwise 349
encourage a small employer to separate or otherwise exclude an 350
employee from health coverage or benefits provided in connection with 351
the employee's employment. 352
(6) No small employer carrier or producer shall disclose (A) to a small 353
employer the fact that any or all of the eligible employees of such small 354
employer have been or will be reinsured with the pool, or (B) to any 355
eligible employee or dependent the fact that he has been or will be 356
reinsured with the pool. 357
(7) If a small employer carrier enters into a contract, agreement or 358
other arrangement with another party to provide administrative, 359
marketing or other services related to the offering of health benefit plans 360
to small employers in this state, the other party shall be subject to the 361
provisions of this section. 362
(8) The commissioner may adopt regulations, in accordance with the 363
provisions of chapter 54, setting forth additional standards to provide 364
for the fair marketing and broad availability of health benefit plans to 365
small employers. 366
(9) Any violation of subdivisions (3) to (7), inclusive, of this section 367
and of any regulations established under subdivision (8) of this section 368
shall be an unfair and prohibited practice under sections 38a-815 to 38a-369
830, inclusive. 370
Sec. 5. (Effective from passage) (a) For the purposes of this section: 371
(1) "Stop-loss insurance plan" means any insurance policy purchased 372
by any employer, insurer, multiple employer welfare arrangement or 373
other provider of fully insured or self-funded small group health 374
coverage in this state that limits the financial risk of medical costs for 375
such employer, insurer, multiple employer welfare arrangement or 376
other provider of fully insured or self-funded small group health 377 Substitute Bill No. 6710
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coverage; and 378
(2) "Small group" means any employer or other purchaser of a stop-379
loss insurance plan with not more than one hundred employees or 380
members. 381
(b) There is established a task force to study the structure of stop-loss 382
insurance plans and any impact that such plans may have on (1) small 383
groups and such groups' enrollees, and (2) medical spending in this 384
state. 385
(c) The task force shall make recommendations concerning: (1) 386
Measures to ensure access to affordable health care services to 387
purchasers of stop-loss insurance plans and such purchasers' enrollees 388
in health coverage utilizing stop-loss insurance plans; (2) any financial 389
impact that stop-loss insurance plans may have on (A) small groups in 390
this state, (B) enrollees and such enrollees' family members, and (C) the 391
fully insured health insurance market in this state; (3) the appropriate 392
role of stop-loss insurance plans in this state; and (4) consumer 393
protections for small groups, such small groups' enrollees and such 394
enrollees' family members covered by stop-loss insurance plans in this 395
state. 396
(d) The task force shall consist of the following members: 397
(1) Two appointed by the speaker of the House of Representatives, 398
one of whom shall be a representative of a small group in this state 399
utilizing a stop-loss insurance plan, and one of whom shall be a 400
representative of a small group in this state offering health coverage that 401
does not utilize a stop-loss insurance plan; 402
(2) Two appointed by the president pro tempore of the Senate, one of 403
whom shall have experience in managing employee benefits and be 404
knowledgeable with respect to stop-loss insurance in this state, and one 405
of whom shall be an insurance producer licensed in this state and be 406
knowledgeable with respect to stop-loss insurance in this state; 407 Substitute Bill No. 6710
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(3) One appointed by the majority leader of the House of 408
Representatives, who shall be a physician licensed pursuant to chapter 409
370 of the general statutes; 410
(4) One appointed by the majority leader of the Senate, who shall be 411
a representative of an advocacy organization focused on health equity; 412
(5) One appointed by the minority leader of the House of 413
Representatives, who shall be a representative of the Connecticut 414
Association of Health Plans; 415
(6) One appointed by the minority leader of the Senate, who shall be 416
a representative of the Connecticut Business and Industry Association; 417
(7) The Healthcare Advocate, or the Healthcare Advocate's designee; 418
and 419
(8) Three persons appointed by the Governor, one of whom shall be 420
a representative of a labor organization, one of whom shall be a 421
representative of an insurance carrier licensed to issue stop-loss 422
insurance plans in this state and one of whom shall be a representative 423
of a consumer advocacy organization. 424
(e) All initial appointments to the task force shall be made not later 425
than thirty days after the effective date of this section. Any vacancy shall 426
be filled by the appointing authority. 427
(f) The members of the task force shall select one or two chairpersons 428
of the task force from among the members of the task force. Such 429
chairperson or chairpersons shall schedule the first meeting of the task 430
force, which shall be held not later than sixty days after the effective date 431
of this section. 432
(g) The administrative staff of the joint standing committee of the 433
General Assembly having cognizance of matters relating to insurance 434
shall serve as administrative staff of the task force. 435 Substitute Bill No. 6710
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(h) Not later than February 1, 2024, the task force shall submit a report 436
on its findings and recommendations to the joint standing committee of 437
the General Assembly having cognizance of matters relating to 438
insurance, in accordance with the provisions of section 11-4a of the 439
general statutes. The task force shall terminate on the date that it 440
submits such report or February 1, 2024, whichever is later. 441
This act shall take effect as follows and shall amend the following
sections:
Section 1 October 1, 2023 New section
Sec. 2 October 1, 2023 New section
Sec. 3 October 1, 2023 New section
Sec. 4 October 1, 2023 38a-567
Sec. 5 from passage New section
INS Joint Favorable Subst.
APP Joint Favorable