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Laws Explanation Notice Page

 

Federal and Connecticut Health Insurance Equity Laws

 

The Patient Protection and Affordable Care Act (PPACA) requires the establishment of Essential Health Benefits standards for health insurance coverage offered in the state. These federal standards prohibit the discrimination of the health care professions thus requiring health insurers to assure the health professions are able to practice to the full extent of their respective scopes of practice. Connecticut laws mandate health insurers provide coverage for services rendered by a chiropractic doctor to the same extent coverage is provided for services rendered by a medical doctor. However, some health insurance policies do not support the provision of the full scope of services available in the chiropractic profession. This adversely affects patient opportunity to utilize the full breadth of chiropractic services for their general health care needs and brings into question health insurer compliance of federal and state health insurance laws. The federal and state laws regarding the requirements for health insurance for the chiropractic profession include:

 

A.    Federal mandate – Patient Protection and Affordable Care Act

Section 2706:

(a) PROVIDERS.—A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider’s license or certification under applicable State law. This section shall not require that a group health plan or health insurance issuer contract with any health care provider willing to abide by the terms and conditions for participation established by the plan or issuer. Nothing in this section shall be construed as preventing a group health plan, a health insurance issuer, or the Secretary from establishing varying reimbursement rates based on quality or performance measures.

(b) Individuals- The provisions of section 1558 of the Patient Protection and Affordable Care Act (relating to non-discrimination) shall apply with respect to a group health plan or health insurance issuer offering group or individual health insurance coverage.

 

B.    State mandates –Title 38a Insurance

Sec. 38a-507:

Coverage for services performed by chiropractors. Every individual health insurance policy delivered, issued for delivery or renewed in this state on or after October 1, 1989, shall provide coverage for services rendered by a chiropractor licensed under chapter 372 to the same extent coverage is provided for services rendered by a physician, if such chiropractic services (1) treat a condition covered under such policy and (2) are within those services a chiropractor is licensed to perform.

Sec. 38a-534:

Mandatory coverage for chiropractic services. Every group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (6) and (11) of section 38a-469, delivered, issued for delivery or renewed in this state on or after October 1, 1989, shall provide coverage for services rendered by a chiropractor licensed under chapter 372 to the same extent coverage is provided for services rendered by a physician, if such chiropractic services (1) treat a condition covered under such policy and (2) are within those services a chiropractor is licensed to perform.

 


 

 

Sec. 38a-591. Compliance with the Patient Protection and Affordable Care Act. Regulations.

(a) For purposes of this section, “Affordable Care Act” means the Patient Protection and Affordable Care Act, P.L. 111-148, as amended from time to time, and regulations adopted thereunder.

(b) Each insurance company, fraternal benefit society, hospital service corporation, medical service corporation and health care center licensed to do business in the state shall comply with Sections 1251, 1252 and 1304 of the Affordable Care Act and the following Sections of the Public Health Service Act, as amended by the Affordable Care Act: (1) 2701 to 2709, inclusive, 42 USC 300gg et seq.; (2) 2711 to 2719A, inclusive, 42 USC 300gg-11 et seq.; and (3) 2794, 42 USC 300gg-94.

(c) This section shall apply, on and after the effective dates specified in the Affordable Care Act, to insurance companies, fraternal benefit societies, hospital service corporations, medical service corporations and health care centers licensed to do business in the state.

(d) No provision of the general statutes concerning a requirement of the Affordable Care Act shall be construed to supersede a provision of the general statutes that provides greater protection to an insured, except to the extent the latter prevents the application of a requirement of the Affordable Care Act.

(e) The Insurance Commissioner may adopt regulations, in accordance with the provisions of chapter 54, to implement the provisions of this section.

 

Section 38a-591 (Effective July 1, 2016):

(a) For purposes of this section, "Affordable Care Act" means the Patient Protection and Affordable Care Act, P. L. 111-148, as amended from time to time, and regulations adopted thereunder.

(b) Each insurance company, fraternal benefit society, hospital service corporation, medical service corporation and health care center licensed to do business in the state shall comply with Sections 1251, 1252 and 1304 of the Affordable Care Act and the following Sections of the Public Health Service Act, as amended by the Affordable Care Act: (1) 2701 to 2709, inclusive, 42 USC 300gg et seq. ; (2) 2711 to 2719A, inclusive, 42 USC 300gg-11 et seq. ; and (3) 2794, 42 USC 300gg-94.

(c) This section shall apply, on and after the effective dates specified in the Affordable Care Act, to insurance companies, fraternal benefit societies, hospital service corporations, medical service corporations and health care centers licensed to do business in the state.

(d) No provision of the general statutes concerning a requirement of the Affordable Care Act shall be construed to supersede a provision of the general statutes that provides greater protection to an insured, except to the extent the latter prevents the application of a requirement of the Affordable Care Act.

(e) (1) The Insurance Commissioner shall, within available appropriations, evaluate whether insurance companies, fraternal benefit societies, hospital service corporations, medical service corporations and health care centers subject to the Affordable Care Act are in compliance with the requirements under said act, including, but not limited to, the prohibition against discriminatory benefit designs. Any such company, society, corporation or center shall submit to the commissioner, upon request, the following information for a specific health insurance policy or plan: (A) The benefits covered under each of the categories of the essential health benefits package, as defined by the Secretary of Health and Human Services; (B) any coverage exclusions or restrictions on covered benefits, including under the prescription drug benefit; (C) any drug formulary used, the tier structure of such formulary and a list of each prescription drug on such formulary and its tier placement; (D) any applicable coinsurance, copayment, deductible or other out-of-pocket expenses for each covered benefit; and (E) any other information the commissioner deems necessary to evaluate such company, society, corporation or center.

(2) The commissioner shall report annually, within available appropriations, to the joint standing committee of the General Assembly having cognizance of matters relating to insurance on any insurance company, fraternal benefit society, hospital service corporation, medical service corporation or health care center evaluated pursuant to subdivision (1) of this section in the preceding year and the findings of such evaluation.

 

Sec. 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.

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