§ 38a-493 — (Formerly Sec. 38-174k). Mandatory coverage for home health care. Deductibles. Exception from deductible limits for medical savings accounts, Archer MSAs and health savings accounts.

Connecticut § 38a-493

• Jurisdiction: Connecticut
• Title 38a: Insurance
• Ch. 700c: Health Insurance

Text

(a) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6), (10), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage providing reimbursement for home health care to residents in this state. (b) For the purposes of this section and section 38a-494 : (1) “Hospital” means an institution that is primarily engaged in providing, by or under the supervision of physicians, to inpatients (A) diagnostic, surgical and therapeutic services for medical diagnosis, treatment and care of persons who have an injury, sickness or disability, or (B) medical rehabilitation services for the rehabilitation of persons who have an injury, sickness or disability. “Hospital” does not include a residential care home, nursing home, rest home or behavioral health facility, as defined in section 19a-490 ; (2) “Home health care” means the continued care and treatment of a covered person who is under the care of a physician, a physician assistant or an advanced practice registered nurse but only if (A) continued hospitalization would otherwise have been required if home health care was not provided, except in the case of a covered person diagnosed by a physician, a physician assistant or an advanced practice registered nurse as terminally ill with a prognosis of six months or less to live, and (B) the plan covering the home health care is established and approved in writing by such physician, physician assistant or advanced practice registered nurse within seven days following termination of a hospital confinement as a resident inpatient for the same or a related condition for which the covered person was hospitalized, except that in the case of a covered person diagnosed by a physician, a physician assistant or an advanced practice registered nurse as terminally ill with a prognosis of six months or less to live, such plan may be so established and approved at any time irrespective of whether such covered person was so confined or, if such covered person was so confined, irrespective of such seven-day period, and (C) such home health care is commenced within seven days following discharge, except in the case of a covered person diagnosed by a physician, a physician assistant or an advanced practice registered nurse as terminally ill with a prognosis of six months or less to live; (3) “Home health agency” means an agency or organization that meets each of the following requirements: (A) It is primarily engaged in and is federally certified as a home health agency and duly licensed, if such licensing is required, by the appropriate licensing authority, to provide nursing and other therapeutic services; (B) its policies are established by a professional group associated with such agency or organization, including at least one physician, physician assistant or advanced practice registered nurse and at least one registered nurse, to govern the services provided; (C) it provides for full-time supervision of such services by a physician, a physician assistant, an advanced practice registered nurse or a registered nurse; (D) it maintains a complete medical record on each patient; and (E) it has an administrator; and (4) “Medical social services” means services rendered, under the direction of a physician, a physician assistant or an advanced practice registered nurse, by a qualified social worker holding a master's degree from an accredited school of social work, including, but not limited to, (A) assessment of the social, psychological and family problems related to or arising out of such covered person's illness and treatment, (B) appropriate action and utilization of community resources to assist in resolving such problems, and (C) participation in the development of the overall plan of treatment for such covered person. (c) Home health care shall be provided by a home health agency. (d) Home health care shall consist of, but shall not be limited to, the following: (1) Part-time or intermittent nursing care by a registered nurse or by a licensed practical nurse under the supervision of a registered nurse, if the services of a registered nurse are not available; (2) part-time or intermittent home health aide services, consisting primarily of patient care of a medical or therapeutic nature by other than a registered or licensed practical nurse; (3) physical, occupational or speech therapy; (4) medical supplies, drugs and medicines prescribed by a physician, a physician assistant or an advanced practice registered nurse and laboratory services to the extent such charges would have been covered under the policy or contract if the covered person had remained or had been confined in the hospital; and (5) medical social services provided to or for the benefit of a covered person diagnosed by a physician, a physician assistant or an advanced practice registered nurse as terminally ill with a prognosis of six months or less to live. (e) The policy may contain a limitation on the number of home health care visits for which benefits are payable, but the number of such visits shall not be less than eighty in any calendar year or in any continuous period of twelve months for each person covered under a policy or contract, except in the case of a covered person diagnosed by a physician, a physician assistant or an advanced practice registered nurse as terminally ill with a prognosis of six months or less to live, the yearly benefit for medical social services shall not exceed two hundred dollars. Each visit by a representative of a home health agency shall be considered as one home health care visit and four hours of home health aide service shall be considered as one home health care visit. (f) Home health care benefits may be subject to an annual deductible of not more than fifty dollars for each person covered under a policy and may be subject to a coinsurance provision that provides for coverage of not less than seventy-five per cent of the reasonable charges for such services. Such policy may also contain reasonable limitations and exclusions applicable to home health care coverage. A high deductible health plan, as defined in Section 220(c)(2) or Section 223(c)(2) of the Internal Revenue Code of 1986, or any subsequent corresponding internal revenue code of the United States, as amended from time to time, used to establish a medical savings account or an Archer MSA pursuant to Section 220 of said Internal Revenue Code or a health savings account pursuant to Section 223 of said Internal Revenue Code shall not be subject to the deductible limits set forth in this subsection. (g) No policy, except any major medical expense policy as described in subsection (j) of this section, shall be required to provide home health care coverage to persons eligible for Medicare. (h) No insurer, hospital service corporation or health care center shall be required to provide benefits beyond the maximum amount limits contained in its policy. (i) If a person is eligible for home health care coverage under more than one policy, the home health care benefits shall only be provided by that policy that would have provided the greatest benefits for hospitalization if the person had remained or had been hospitalized. (j) Each individual major medical expense policy delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage in accordance with the provisions of this section for home health care to residents in this state whose benefits are no longer provided under Medicare or any applicable individual health insurance policy. See Sec. 38a-520 for similar provisions re group policies.

Legislative History

(P.A. 75-623, S. 1; P.A. 78-76, S. 1–3, 5; P.A. 84-375, S. 1, 3; P.A. 89-284; P.A. 90-243, S. 83; P.A. 96-19, S. 6; P.A. 97-112, S. 2; P.A. 03-78, S. 1; P.A. 04-174, S. 6; P.A. 11-19, S. 41, 43; P.A. 16-39, S. 59; P.A. 17-15, S. 54; 17-202, S. 88; July Sp. Sess. P.A. 20-4, S. 15; P.A. 21-196, S. 64; P.A. 22-58, S. 44; 22-92, S. 11.) History: P.A. 78-76 specified applicability or inapplicability of provisions with respect to persons diagnosed as terminally ill with six months or less to live in Subsecs. (b), (d) and (e) and added “or had been” in Subsec. (i) preceding “hospitalized”; P.A. 84-375 amended Subsec. (g) to exclude major medical expense policies, as described in Subsec. (j), from the exemption in the subsection and added Subsec. (j), requiring that each major medical policy delivered, issued or renewed on or after October 1, 1984, provide coverage for home health care to residents who have exhausted their other policy or contract benefits; P.A. 89-284 amended Subsec. (b) to include a definition of “hospital” and amended Subsec. (j) to clarify that home health care shall be provided in accordance with this section under the major medical policies of insureds whose benefits are no longer provided under Medicare; P.A. 90-243 substituted references to “health insurance policies” for references to hospital and medical expense policies or contracts, added reference to health care centers and specified applicability solely to individual policies (Revisor's note: The reference to “or contract” at the end of Subsec. (h) was deleted editorially by the Revisors for conformity with the changes made by P.A. 90-243); Sec. 38-174k transferred to Sec. 38a-493 in 1991; P.A. 96-19 expanded reference in Subsec. (d) to prescriptions by physicians to include advanced practice registered nurses and physician assistants; P.A. 97-112 replaced “home for the aged” with “residential care home”; P.A. 03-78 amended Subsec. (f) to provide that a high deductible health plan shall not be subject to the deductible limits set forth in said Subsec., effective July 1, 2003; P.A. 04-174 amended Subsec. (f) to add references to “Archer MSA”, “health savings account” and Section 223 of the Internal Revenue Code re “high deductible health plans”, effective June 1, 2004; P.A. 11-19 inserted “amended or continued” and made technical changes in Subsecs. (a) and (j), effective January 1, 2012; P.A. 16-39 amended Subsecs. (b) to (e) by adding references to advanced practice registered nurse and made technical changes; P.A. 17-15 amended Subsec. (b) by adding reference to Sec. 38a-494, designating existing provisions defining “hospital” as Subdiv. (1), designating existing provisions defining “home health care” as Subdiv. (2), redesignating provisions of existing Subsec. (c) defining “home health agency” as Subsec. (b)(3) and redesignating provisions of existing Subsec. (d) defining “medical social services” as Subsec. (b)(4), and made technical and conforming changes; P.A. 17-202 amended Subsec. (b) by replacing “injured, disabled or sick persons” with “persons who have an injury, sickness or disability” in Subdivs. (1) and (2); July Sp. Sess. P.A. 20-4 amended Subsec. (f) by substituting “high deductible health plan” for “high deductible plan”; P.A. 21-196 amended Subsecs. (b), (d) and (e) by adding references to physician assistant and made a technical change in Subsec. (d); P.A. 22-58 amended Subsec. (b)(1) by replacing “alcohol or drug treatment facility” with “behavioral health facility”; P.A. 22-92 amended Subsec. (d)(4) by making a technical change, effective May 24, 2022.