§ 38a-567 — Provisions of small employer plans and arrangements.

Connecticut § 38a-567

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

Text

Health insurance plans, associations of small employers and other insurance arrangements covering small employers and insurers and producers marketing such plans and arrangements shall be subject to the following provisions: (1) (A) Any such plan or arrangement shall be offered on a guaranteed issue basis with respect to all eligible employees or dependents of such employees, at the option of the small employer, policyholder or contractholder, as the case may be. (B) Any such plan or arrangement shall be renewable with respect to all eligible employees or dependents at the option of the small employer, policyholder or contractholder, as the case may be, except: (i) For nonpayment of the required premiums by the small employer, policyholder or contractholder; (ii) for fraud or misrepresentation of the small employer, policyholder or contractholder or, with respect to coverage of individual insured, the insureds or their representatives; (iii) for noncompliance with plan or arrangement provisions; (iv) when the number of insureds covered under the plan or arrangement is less than the number of insureds or percentage of insureds required by participation requirements under the plan or arrangement; or (v) when the small employer, policyholder or contractholder is no longer actively engaged in the business in which it was engaged on the effective date of the plan or arrangement. (C) Renewability of coverage may be effected by either continuing in effect a plan or arrangement covering a small employer or by substituting upon renewal for the prior plan or arrangement the plan or arrangement then offered by the carrier that most closely corresponds to the prior plan or arrangement and is available to other small employers. Such substitution shall only be made under conditions approved by the commissioner. A carrier may substitute a plan or arrangement as set forth in this subparagraph only if the carrier effects the same substitution upon renewal for all small employers previously covered under the particular plan or arrangement, unless otherwise approved by the commissioner. The substitute plan or arrangement shall be subject to the rating restrictions specified in this section on the same basis as if no substitution had occurred, except for an adjustment based on coverage differences. (D) Any such plan or arrangement shall provide special enrollment periods (i) to all eligible employees or dependents as set forth in 45 CFR 147.104, as amended from time to time, and (ii) for coverage under such plan or arrangement ordered by a court for a spouse or minor child of an eligible employee where request for enrollment is made not later than thirty days after the issuance of such court order. (2) (A) As used in this subdivision, “grandfathered plan” has the same meaning as “grandfathered health plan” as provided in the Patient Protection and Affordable Care Act, P.L. 111-148, as amended from time to time. (B) With respect to grandfathered plans issued to small employers, the premium rates charged or offered shall be established on the basis of a single pool of all grandfathered plans, adjusted to reflect one or more of the following classifications: (i) Age, provided age brackets of less than five years shall not be utilized; (ii) Gender; (iii) Geographic area, provided an area smaller than a county shall not be utilized; (iv) Industry, provided the rate factor associated with any industry classification shall not vary from the arithmetic average of the highest and lowest rate factors associated with all industry classifications by greater than fifteen per cent of such average, and provided further, the rate factors associated with any industry shall not be increased by more than five per cent per year; (v) Group size, provided the highest rate factor associated with group size shall not vary from the lowest rate factor associated with group size by a ratio of greater than 1.25 to 1.0; (vi) Administrative cost savings resulting from the administration of an association group plan or a plan written pursuant to section 5-259 , provided the savings reflect a reduction to the small employer carrier's overall retention that is measurable and specifically realized on items such as marketing, billing or claims paying functions taken on directly by the plan administrator or association, except that such savings may not reflect a reduction realized on commissions; (vii) Savings resulting from a reduction in the profit of a carrier that writes small business plans or arrangements for an association group plan or a plan written pursuant to section 5-259 , provided any loss in overall revenue due to a reduction in profit is not shifted to other small employers; and (viii) Family composition, provided the small employer carrier shall utilize only one or more of the following billing classifications: (I) Employee; (II) employee plus family; (III) employee and spouse; (IV) employee and child; (V) employee plus one dependent; and (VI) employee plus two or more dependents. (C) (i) With respect to nongrandfathered plans issued to small employers, the premium rates charged or offered shall be established on the basis of a single pool of all nongrandfathered plans, adjusted to reflect one or more of the following classifications: (I) Age, in accordance with a uniform age rating curve established by the commissioner; (II) Geographic area, as defined by the commissioner. (ii) Total premium rates for family coverage for nongrandfathered plans shall be determined by adding the premiums for each individual family member, except that with respect to family members under twenty-one years of age, the premiums for only the three oldest covered children shall be taken into account in determining the total premium rate for such family. (iii) Premium rates for employees and dependents for nongrandfathered plans shall be calculated for each covered individual and premium rates for the small employer group shall be calculated by totaling the premiums attributable to each covered individual. (iv) Premium rates for any given plan may vary by (I) actuarially justified differences in plan design, and (II) actuarially justified amounts to reflect the policy's provider network and administrative expense differences that can be reasonably allocated to such policy. (3) No small employer carrier or producer shall, directly or indirectly, engage in the following activities: (A) Encouraging or directing small employers to refrain from filing an application for coverage with the small employer carrier because of the health status, claims experience, industry, occupation or geographic location of the small employer, except the provisions of this subparagraph shall not apply to information provided by a small employer carrier or producer to a small employer regarding the carrier's established geographic service area or a restricted network provision of a small employer carrier; or (B) Encouraging or directing small employers to seek coverage from another carrier because of the health status, claims experience, industry, occupation or geographic location of the small employer. (4) No small employer carrier shall, directly or indirectly, enter into any contract, agreement or arrangement with a producer that provides for or results in the compensation paid to a producer for the sale of a health benefit plan to be varied because of the health status, claims experience, industry, occupation or geographic area of the small employer. A small employer carrier shall provide reasonable compensation, as provided under the plan of operation of the program, to a producer, if any, for the sale of a health care plan. No small employer carrier shall terminate, fail to renew or limit its contract or agreement of representation with a producer for any reason related to the health status, claims experience, occupation, or geographic location of the small employers placed by the producer with the small employer carrier. (5) No small employer carrier or producer shall induce or otherwise encourage a small employer to separate or otherwise exclude an employee from health coverage or benefits provided in connection with the employee's employment. (6) No small employer carrier or producer shall disclose (A) to a small employer the fact that any or all of the eligible employees of such small employer have been or will be reinsured with the pool, or (B) to any eligible employee or dependent the fact that he has been or will be reinsured with the pool. (7) If a small employer carrier enters into a contract, agreement or other arrangement with another party to provide administrative, marketing or other services related to the offering of health benefit plans to small employers in this state, the other party shall be subject to the provisions of this section. (8) The commissioner may adopt regulations, in accordance with the provisions of chapter 54, setting forth additional standards to provide for the fair marketing and broad availability of health benefit plans to small employers. (9) Any violation of subdivisions (3) to (7), inclusive, of this section and of any regulations established under subdivision (8) of this section shall be an unfair and prohibited practice under sections 38a-815 to 38a-830 , inclusive.

Legislative History

(P.A. 90-134, S. 18, 28; P.A. 91-201, S. 2, 8; P.A. 92-125, S. 3, 5; P.A. 93-137, S. 3, 6; 93-345, S. 4; P.A. 94-214, S. 3, 4; P.A. 96-193, S. 14, 36; P.A. 99-59, S. 1; P.A. 04-163, S. 2; P.A. 05-238, S. 4, 5; P.A. 08-33, S. 2, 3; 08-181, S. 3; P.A. 10-4, S. 2; 10-13, S. 5; P.A. 11-19, S. 15; 11-58, S. 48; P.A. 14-235, S. 31; P.A. 15-247, S. 19, 20.) History: P.A. 91-201 clarified the renewability provisions concerning small employer plans and the insurer's right to rescind coverage based on fraud or misrepresentation and eliminating an insurance carrier's ability to pass through reinsurance premiums; P.A. 92-125 made numerous changes and additions concerning renewability of coverage when a product line is discontinued, conditions under which reenrollment is permitted when coverage is rescinded for fraud, limits on range in rates, differences in plan design used for premium rates for plans, liberalizing of preexisting condition credits, reducing the maximum allowable percentage increase in rates and establishing requirements for fair marketing of health benefit plans; P.A. 93-137 applied provisions to insurers, agents and brokers marketing small employer health plans and arrangements, amended Subdiv. (4) to disallow exclusion for those employees or dependents previously covered under a prior small employer health plan issued pursuant to workers' compensation or COBRA who request such coverage on a timely basis, inserted a new Subdiv. (17) re disclosure to a small employer or employee or dependent concerning reinsurance of covered persons with pool, made technical changes for statutory consistency, renumbered the remaining Subdivs. and amended internal references, effective June 11, 1993; P.A. 93-345 deleted Subdivs. (1) and (2) re preexisting condition coverage, Subdiv. (5) re maximum allowable premium rate charged, Subdivs. (6) and (7) re increase in premium rates for rating periods prior to October 1, 1992, amended Subdiv. (1)(D) re application of modification of premium rates not permitted after July 1, 1995, inserted new Subdiv. (3) re caps on premiums for rating periods October 1, 1993 to June 30, 1994, and from July 1, 1994, to July 1, 1995, amended Subdiv. (4) to change October 1, 1992, to October 1, 1993, and added prior to July 1, 1995, deleted 15% annual adjustment and inserted 10% and 5% for October 1, 1993, to June 30, 1994, and July 1, 1994, to July 1, 1995 rating period respectively, added new Subdiv. (5) re adjusted community rating, added new Subdiv. (19) re time for quotation and made technical changes; P.A. 94-214 amended Subdiv. (3) to specify its inapplicability to any small employers who employ more than 25 eligible employees and amended Subdiv. (4) to specify applicability of maximum increase in the premium rate charged to a small employer who employs not more than 25 eligible employees, effective July 1, 1994; P.A. 96-193 substituted “producer” for “agent” and “broker”, effective June 3, 1996; P.A. 99-59 amended Subdiv. (21) to substitute “38a-830” for “38a-831”; P.A. 04-163 inserted new Subdiv. (5)(A)(vi) to include administrative cost savings as a community rating classification, renumbered existing Subdiv. (5)(A)(vi) as Subdiv. (5)(A)(vii) and amended same to change subclause designators (a) to (f), inclusive, to (I) to (VI), inclusive, effective July 1, 2004; P.A. 05-238 inserted new Subdiv. (5)(A)(vii) re savings resulting from a reduction in profit, and redesignated existing Subdiv. (5)(A)(vii) as Subdiv. (5)(A)(viii) and added new Subdiv. (22) re premium rates of plans or arrangements under Sec. 5-259 and association group plans that are not subject to section, effective July 8, 2005; P.A. 08-33 amended Subdiv. (10) to make technical changes, add “that is self-employed” re small employer and delete references to special health care plans from small employer carriers, and amended Subdiv. (18) to make a technical change, effective May 7, 2008; P.A. 08-181 amended Subdiv. (22) by designating existing provisions as Subpara. (A), making conforming changes therein, deleting references to association group plan and reducing number of covered lives required from 10,000 eligible individuals to 3,000 employees, and by adding Subpara. (B) re association group plans; P.A. 10-4 amended Subdiv. (1) to add new Subpara. (A) re premium quotes for small employers and redesignate existing Subparas. (A) to (D) as Subparas. (B) to (E), effective January 1, 2011; P.A. 10-13 amended Subdiv. (2) to change reference re continuation of coverage from federal COBRA to Sec. 38a-554, and made technical changes in Subdiv. (21), effective May 5, 2010; P.A. 11-19 made a technical change in Subdiv. (18); P.A. 11-58 inserted “intentional” re misrepresentation or concealment in Subdiv. (1)(D), effective July 2, 2011; P.A. 14-235 made a technical change in Subdiv. (2); P.A. 15-247 amended introductory language by adding reference to associations of small employers, amended Subdiv. (1) by deleting former Subpara. (A) re offering and acceptance of premium quotes, adding new Subpara. (A) re offering plan or arrangement on guaranteed issue basis, making a technical change in Subpara. (C), deleting former Subparas. (D) and (E) re rescission of plan or arrangement and individual whose coverage is subsequently rescinded, and adding new Subpara. (D) re special enrollment periods for plan or arrangement, deleted former Subdiv. (2) re exclusion of eligible employee or dependent on basis of health condition who would otherwise be covered, deleted former Subdivs. (3) and (4) re rating periods, redesignated existing Subdiv. (5) as Subdiv. (2) and amended same by adding new Subpara. (A) re definition of “grandfathered plan”, designating existing Subpara. (A) as Subpara. (B) and amending same to replace “community rate” with “single pool of all grandfathered plans”, deleting former Subparas. (B) and (C) re quote of premium rates and application of subdivision, and adding new Subpara. (C) re nongrandfathered plan requirements, deleted former Subdivs. (6) to (9) re permitted bases and requirements for premium rate variations, deleted former Subdiv. (10) re denial of coverage to self-employed small employer, redesignated existing Subdiv. (11) as Subdiv. (3), redesignated existing Subdiv. (12) as Subdiv. (4) and amended same by deleting “special or a small employer”, redesignated existing Subdivs. (13), (15) to (17) and (21) as Subdivs. (5) to (9), respectively, deleted former Subdiv. (14) re denial by small employer carrier, deleted former Subdiv. (18) re small employer carrier maintenance of rating practices and renewal underwriting practices, deleted former Subdiv. (19) re commissioner authority to suspend parts of section relating to small employer premium rates, deleted former Subdiv. (20) re 30-day period for quoting premium rates to small employer, deleted former Subdiv. (22) re exemption of certain plans or arrangements from section, and made technical and conforming changes, effective July 10, 2015, and amended Subdiv. (2)(C) by adding provision re actuarially adjusted amounts to reflect provider network and administrative expense differences, effective January 1, 2016.