§ 38a-1086 — Certification of health benefit plans.

(a) The exchange may certify a health benefit plan as a qualified health plan if: (1) The plan includes, at a minimum, essential benefits as determined under the Affordable Care Act and the coverage requirements under chapter 700c, except that the plan shall not be required to provide essential benefits that duplicate the minimum benefits of qualified dental plans, as set forth in subsection (e) of this section, if: (A) The exchange has determined that at least one qualified dental plan is available to supplement the plan's coverage; and (B) The health carrier makes prominent disclosure at the time it offers the plan, in a form approved by the exchange, that such plan does not provide the full range of essential pediatric benefits, and that qualified dental plans providing those benefits and other dental benefits not covered by such plan are offered through the exchange; (2) The premium rates and contract language have been approved by the commissioner; (3) The plan provides at least a bronze level of coverage, as determined pursuant to subdivision (8) of section 38a-1084 , unless the plan is certified as a qualified catastrophic plan, meets the requirements of the Affordable Care Act for catastrophic plans and will only be offered to individuals eligible for catastrophic coverage; (4) The plan's cost-sharing requirements do not exceed the limits established under Section 1302(c)(1) of the Affordable Care Act, and if the plan is offered through the program for small employers, the plan's deductible does not exceed the limits established under Section 1302(c)(2) of the Affordable Care Act; (5) The health carrier offering the plan: (A) Is licensed and in good standing to offer health insurance coverage in the state; (B) Agrees to offer at least (i) one qualified health plan at a silver level of coverage, as determined pursuant to subdivision (8) of section 38a-1084 , and (ii) one qualified health plan at a gold level of coverage, as determined pursuant to subdivision (8) of section 38a-1084 , through each component of the exchange in which the health carrier participates, where “component” refers to the program for small employers and the program for individual coverage; (C) Charges the same premium rate for each qualified health plan without regard to whether the plan is offered through the exchange or directly by the health carrier or through an insurance producer; (D) Does not charge any cancellation fees or penalties as set forth in subsection (c) of section 38a-1085 ; and (E) Complies with the regulations developed by the Secretary under Section 1311(d) of the Affordable Care Act and such other requirements as the exchange may establish; (6) The plan meets the requirements for certification pursuant to written procedures adopted under subsection (a) of section 38a-1082 and regulations promulgated by the Secretary under Section 1311(c) of the Affordable Care Act; and (7) The exchange determines that making the plan available through the exchange is in the interest of qualified individuals and qualified employers in the state. (b) The exchange shall not refuse to certify a health benefit plan as a qualified health plan: (1) On the basis that (A) the plan is a fee-for-service plan, or (B) the health benefit plan provides treatments necessary to prevent patients' deaths in circumstances the exchange determines are inappropriate or too costly; or (2) By conditioning such certification on the imposition of premium price controls by the exchange. (c) The exchange shall require each health carrier seeking certification of a health benefit plan as a qualified health plan to: (1) Agree to submit a justification for any premium increase before implementation of such increase. The health carrier shall prominently post such justification and any information related to such justification on its Internet web site. The exchange shall take such justification and information into consideration, along with (A) any additional information and recommendations provided to the exchange by the commissioner under Section 2794(b) of the Public Health Service Act, 42 USC 300gg-94, as amended from time to time, and (B) any excess of premium growth outside the exchange as compared to the rate of such growth inside the exchange, including information reported by other states to the Secretary, when determining whether to allow the health carrier to continue to make such plan available through the exchange; (2) Make available to the public in plain language, as that term is defined in Section 1311(e)(3)(B) of the Affordable Care Act, and submit to the exchange, the Secretary and the commissioner, accurate and timely disclosure of the following for such plan: (A) Claims payment policies and practices; (B) Periodic financial disclosures; (C) Data on enrollment; (D) Data on disenrollment; (E) Data on the number of claims that are denied; (F) Data on rating practices; (G) Information on cost-sharing and payments with respect to any out-of-network coverage; (H) Information on enrollee and participant rights under Title I of the Affordable Care Act; and (I) Other information determined as appropriate by the Secretary; and (3) Permit individuals to learn, in a timely manner upon the request of the individual, the amount of cost-sharing, including deductibles, copayments and coinsurance, under the individual's plan or coverage that such individual would be responsible for paying with respect to the furnishing of a specific item or service by a participating provider. At a minimum, this information shall be made available to the individual through an Internet web site and through other means for individuals without access to the Internet. (d) The exchange shall not exempt any health carrier seeking certification of a health benefit plan as a qualified health plan from state licensure or reserve requirements and shall apply the criteria of this section in a manner that assures a level playing field between or among health carriers participating in the exchange. (e) (1) The provisions of sections 38a-1080 to 38a-1090 , inclusive, that are applicable to qualified health plans, shall also apply to the extent applicable to qualified dental plans, except as modified in accordance with the provisions of subdivisions (2), (3) and (4) of this subsection or by written procedures adopted by the exchange. (2) A health carrier seeking certification of a dental benefit plan as a qualified dental plan shall be licensed in the state to offer dental coverage, but need not be licensed to offer other health benefits. (3) Qualified dental plans shall be limited to dental and oral health benefits, without substantial duplication of the benefits typically offered by health benefit plans without dental coverage and shall include, at a minimum, the essential pediatric dental benefits prescribed by the Secretary pursuant to Section 1302(b)(1)(J) of the Affordable Care Act, and such other dental benefits as the exchange may specify or the Secretary may specify by regulation. (4) Health carriers may jointly offer a comprehensive plan through the exchange in which dental benefits are provided by a health carrier through a qualified dental plan and health benefits are provided by another health carrier through a qualified health plan, provided the plans are priced separately and are also made available for purchase separately at the same such prices.

Legislative History

(P.A. 11-53, S. 8.) History: P.A. 11-53 effective July 1, 2011 (Revisor's note: In Subdiv. (3), a reference to “subdivision (6) of section 38a-1084” was changed editorially by the Revisors to “subdivision (8) of section 38a-1084” for accuracy).