(a) As used in this section and section 38a-479rr:
(1) “Affiliate” means a person that directly or indirectly through one or more intermediaries, controls, or is controlled by, or is under common control with, a health insurer, health care center, hospital service corporation, medical service corporation or fraternal benefit society licensed in this state;
(2) “Consumer” means: (A) A person to whom a medical discount plan is marketed or advertised, or (B) a member, as defined in this subsection;
(3) “Marketer” means a person that markets, advertises or sells a medical discount plan, including, but not limited to, an entity that markets, advertises or sells a medical discount plan under its own name;
(4) “Medical discount plan” means a business arrangement or contract in which a person, in exchange for payment, provides access for its members to providers of health care services and the right to receive health care services from those providers at a discount. “Medical discount plan” does not include a product that (A) is otherwise subject to regulation or approval under this title, or (B) costs less than twenty-five dollars, annually, in the aggregate;
(5) “Medical discount plan organization” means a person that (A) establishes a medical discount plan, (B) contracts with providers, provider networks or other medical discount plan organizations to provide health care services at a discount to medical discount plan members, and (C) determines the fees charged to the members for the medical discount plan. “Medical discount plan organization” does not include a health insurer, health care center, hospital service corporation, medical service corporation or fraternal benefit society licensed in this state or any affiliate of such health insurer, health care center, hospital service corporation, medical service corporation or fraternal benefit society;
(6) “Health care services” means any care, service or treatment of an illness or dysfunction of, or injury to, the human body. “Health care services” includes physician care, inpatient care, hospital surgical services, emergency medical services, ambulance services, dental care services, vision care services, mental health care services, substance abuse services, chiropractic services, podiatric services, laboratory test services and the provision of medical equipment or supplies. “Health care services” does not include pharmaceutical supplies or prescriptions;
(7) “Member” means an individual who pays for the right to receive the benefits of a medical discount plan; and
(8) “Person” has the same meaning as provided in section 38a-1.
(b) No person shall market, advertise or sell to a resident of this state a medical discount plan or any plan material that: (1) Fails to provide to the consumer a clear and conspicuous disclosure that the medical discount plan is not insurance and that the plan only provides for discounted health care services from participating providers within the plan; (2) uses in its marketing materials, advertisements, brochures or member discount cards the term “insurance”, “health plan”, “coverage”, “copay”, “copayments”, “preexisting conditions”, “guaranteed issue”, “premium”, “PPO”, “preferred provider organization” or any other term that could reasonably mislead a person into believing the medical discount plan is insurance, except that such terms may be used as a disclaimer of any relationship between the medical discount plan and insurance; (3) fails to provide the name, address and telephone number of the administrator of the medical discount plan; (4) fails to make available to the consumer through a toll-free telephone number, upon request of the consumer, a complete and accurate list of the participating providers within the plan in the consumer's local area and a list of the services for which the discounts are applicable; (5) fails to make a printed copy of such list available to the consumer upon request commencing with the time the plan is purchased or fails to update the list at least once every six months; (6) fails to use plain language to describe the discounts or access to discounts offered and such failure results in representations of the discounts that are misleading, deceptive or fraudulent; (7) fails to provide the consumer notice of the right to cancel such medical discount plan; (8) offers discounted health care services or products that are not authorized by a contract with each provider listed in conjunction with the medical discount plan; (9) fails to allow a consumer to cancel a medical discount plan not later than thirty days after the date payment is received by the medical discount plan; (10) with respect to a consumer who cancels a medical discount plan pursuant to subdivision (9) of this subsection, fails to guarantee a refund of all membership fees paid to the medical discount plan by the consumer, excluding a reasonable one-time processing fee, not later than thirty days after the member gives timely notification of cancellation of the plan to the medical discount plan organization; or (11) fails to (A) provide at least one member discount card for each member as proof of membership, and (B) prominently display on such member discount card a statement that the medical discount plan is not insurance.
(c) Any person who knowingly operates as a medical discount plan organization in violation of this section shall be fined not more than fifteen thousand dollars. Any person who knowingly aids and abets another that the person knew or reasonably should have known was operating as a medical discount plan organization in violation of this section shall be fined not more than fifteen thousand dollars.
(d) Any person who collects fees for purported membership in a medical discount plan but fails to provide the promised benefits shall be subject to the penalties for larceny under sections 53a-122 to 53a-125b, inclusive, depending on the amount involved. Upon the conviction of such person of larceny, as defined in section 53a-119, if the court does not order financial restitution pursuant to section 53a-28, the commissioner may order reimbursement of any membership fees paid by residents of the state who were harmed by such offense.
(e) Any person licensed in this state as a health insurer, health care center, hospital service corporation, medical service corporation or fraternal benefit society, or any affiliate owned or controlled by such health insurer, health care center, hospital service corporation, medical service corporation or fraternal benefit society, may offer medical discount plans in this state pursuant to such licensure.
(P.A. 05-237, S. 1; P.A. 08-178, S. 51; 08-181, S. 1; P.A. 17-15, S. 47.)
History: P.A. 05-237 effective July 1, 2005; P.A. 08-178 increased maximum fines from $10,000 to $15,000 in Subsec. (c); P.A. 08-181 added Subsec. (a)(3) defining “marketer”, redesignated existing Subsecs. (a)(3) to (a)(7) as new Subsecs. (a)(4) to (a)(8), amended Subsec. (b) by changing “may” to “shall”, and amended Subsec. (d) by authorizing commissioner to order additional penalty of membership fees reimbursement; P.A. 17-15 made a technical change in Subsec. (a)(8).
Structure Connecticut General Statutes
Chapter 700c - Health Insurance
Section 38a-469. - Definitions.
Section 38a-472a. - Medical provider indemnification agreements prohibited.
Section 38a-472g. - Restrictions applicable to prior authorization or precertification.
Section 38a-472j. - Restrictions applicable to cost-sharing for covered benefits. Regulations.
Section 38a-472k. - Disability income policies. Discretionary clauses prohibited. Regulations.
Section 38a-476. - Preexisting condition coverage.
Section 38a-476b. - Standards re psychotropic drug availability in health plans.
Section 38a-477. - Standardized claim forms. Information necessary for filing a claim. Regulations.
Section 38a-477a. - Notification by Insurance Commissioner of required benefits and policy forms.
Section 38a-477bb. - Cost-sharing re facility fees.
Section 38a-477f. - Contract provision prohibiting certain disclosures prohibited.
Section 38a-477ff. - Third-party discounts and payments for covered benefits. Credit required.
Section 38a-477g. - Contracts between health carriers and participating providers.
Section 38a-477h. - Participating provider directories.
Section 38a-477ll. - Coverage for health enhancement programs.
Section 38a-478. - Definitions.
Section 38a-478a. - Commissioner's report to the Governor and the General Assembly.
Section 38a-478f. - Provider profile development requirements.
Section 38a-478g. - Managed care contract requirements. Plan description requirements.
Section 38a-478i. - Limitation on enrollee rights prohibited.
Section 38a-478j. - Coinsurance and deductible payments based on negotiated discounts.
Section 38a-478k. - Gag clauses prohibited.
Section 38a-478l. - Consumer report card required. Content. Data analysis by commissioner.
Section 38a-478o. - Confidentiality and antidiscrimination procedures required.
Section 38a-478p. - Expedited utilization review. Standardized process required.
Section 38a-478q. - Use of laboratories covered by plan required.
Section 38a-478t. - Commissioner of Public Health to receive data.
Section 38a-478u. - Regulations.
Section 38a-479. - Definitions. Access to fee schedules. Fee information to be confidential.
Section 38a-479gg. - Regulations.
Section 38a-479aaa. - Pharmacy benefits managers. Definitions.
Section 38a-479ddd. - Hearing on denial of certificate. Subsequent application.
Section 38a-479eee. - Claims payment to be made by electronic funds transfer upon written request.
Section 38a-479fff. - Expiration of certificates of registration. Renewal. Fees.
Section 38a-479ggg. - Regulations.
Section 38a-479hhh. - Investigations and hearings. Powers of commissioner. Appeals.
Section 38a-479iii. - Pharmacy audits.
Section 38a-479ooo. - Definitions.
Section 38a-479qqq. - Annual report by health carriers. Regulations.
Section 38a-479rrr. - Annual certification by health carriers.
Section 38a-479qq. - Medical discount plans: Definitions, prohibited sales practices, penalties.
Section 38a-482. (Formerly Sec. 38-166). - Form of policy.
Section 38a-482c. - Annual and lifetime limits.
Section 38a-483. (Formerly Sec. 38-167). - Standard provisions of individual health policy.
Section 38a-483a. - Exclusionary riders for individual health insurance policies. Regulations.
Section 38a-483b. - Time limits for coverage determinations. Notice requirements.
Section 38a-483c. - Coverage and notice re experimental treatments. Appeals.
Section 38a-486. (Formerly Sec. 38-170). - Certain acts not to operate as waiver of rights.
Section 38a-487. (Formerly Sec. 38-171). - Coverage after termination date of policy.
Section 38a-488. (Formerly Sec. 38-172). - Discrimination.
Section 38a-488b. - Coverage for autism spectrum disorder therapies.
Section 38a-488d. - Coverage for substance abuse services provided pursuant to court order.
Section 38a-488e. - Coverage for mental health wellness examinations.
Section 38a-488f. - Coverage for services provided under the Collaborative Care Model.
Section 38a-488g. - Acute inpatient psychiatric coverage. Prior authorization not required.
Section 38a-490a. - Coverage for birth-to-three program.
Section 38a-490b. - Coverage for hearing aids.
Section 38a-490c. - Coverage for craniofacial disorders.
Section 38a-490d. - Mandatory coverage for blood lead screening and risk assessment.
Section 38a-491b. - Assignment of benefits to a dentist or oral surgeon.
Section 38a-492a. - Mandatory coverage for hypodermic needles and syringes.
Section 38a-492b. - Coverage for certain off-label drug prescriptions.
Section 38a-492d. - Mandatory coverage for diabetes screening, testing and treatment.
Section 38a-492e. - Mandatory coverage for diabetes outpatient self-management training.
Section 38a-492f. - Mandatory coverage for certain prescription drugs removed from formulary.
Section 38a-492g. - Mandatory coverage for prostate cancer screening and treatment.
Section 38a-492h. - Mandatory coverage for certain Lyme disease treatments.
Section 38a-492i. - Mandatory coverage for pain management.
Section 38a-492j. - Mandatory coverage for ostomy-related supplies.
Section 38a-492k. - Mandatory coverage for colorectal cancer screening.
Section 38a-492m. - Mandatory coverage for certain renewals of prescription eye drops.
Section 38a-492n. - Mandatory coverage for certain wound-care supplies.
Section 38a-492o. - Mandatory coverage for bone marrow testing.
Section 38a-492p. - Mandatory coverage for medically monitored inpatient detoxification.
Section 38a-492q. - Mandatory coverage for essential health benefits.
Section 38a-492t. - Mandatory coverage for prosthetic devices.
Section 38a-492u. - Coverage for psychotropic drugs. Standards re availability.
Section 38a-494. (Formerly Sec. 38-174l). - Home health care by recognized nonmedical systems.
Section 38a-495b. - Medicare supplement policies and certificates. Definitions.
Section 38a-495d. - Refund of prepaid premium for Medicare supplement policies.
Section 38a-496. (Formerly Sec. 38-174q). - Coverage for occupational therapy.
Section 38a-498a. - Prior authorization prohibited for certain 9-1-1 emergency calls.
Section 38a-498b. - Mandatory coverage for mobile field hospital.
Section 38a-503a. - Mandatory coverage for breast cancer survivors.
Section 38a-503b. - Carriers to permit direct access to obstetrician-gynecologist.
Section 38a-503e. - Mandatory coverage for contraceptives and sterilization.
Section 38a-503g. - Mandatory coverage for ovarian cancer screening and monitoring.
Section 38a-504a. - Coverage for routine patient care costs associated with certain clinical trials.
Section 38a-504b. - Clinical trial criteria.
Section 38a-504d. - Clinical trials: Routine patient care costs.
Section 38a-504e. - Clinical trials: Billing. Payments.
Section 38a-504g. - Clinical trials: Submission and certification of policy forms.
Section 38a-506. (Formerly Sec. 38-173). - Penalty.
Section 38a-507. - Coverage for services performed by chiropractors.
Section 38a-508. - Coverage for adopted children.
Section 38a-509. - Mandatory coverage for infertility diagnosis and treatment. Limitations.
Section 38a-510. - Prescription drug coverage. Mail order pharmacies. Step therapy use.
Section 38a-510a. - Prescription drug coverage. Synchronized refills.
Section 38a-511. - Copayments re in-network imaging services.
Section 38a-512. - Applicability of statutes to certain major medical expense policies.
Section 38a-512a. - Continuation of coverage.
Section 38a-512c. - Annual and lifetime limits.
Section 38a-513a. - Time limits for coverage determinations. Notice requirements.
Section 38a-513b. - Coverage and notice re experimental treatments. Appeals.
Section 38a-513f. - Claims information to be provided to certain employers. Restrictions. Subpoenas.
Section 38a-513g. - Employer submission of plan cost information to Comptroller.
Section 38a-514a. - Biologically-based mental illness. Coverage required.
Section 38a-514b. - Coverage for autism spectrum disorder.
Section 38a-514d. - Coverage for substance abuse services provided pursuant to court order.
Section 38a-514e. - Coverage for mental health wellness exams.
Section 38a-514f. - Coverage for services provided under the Collaborative Care Model.
Section 38a-514g. - Acute patient psychiatric coverage. Prior authorization not required.
Section 38a-515. - Continuation of coverage of mentally or physically handicapped children.
Section 38a-516. - Coverage for newly born children. Notification to insurer.
Section 38a-516a. - Coverage for birth-to-three program.
Section 38a-516b. - Coverage for hearing aids.
Section 38a-516c. - Coverage for craniofacial disorders.
Section 38a-516d. - Coverage for neuropsychological testing for children diagnosed with cancer.
Section 38a-517. - Coverage for services performed by dentist in certain instances.
Section 38a-517b. - Assignment of benefits to a dentist or oral surgeon.
Section 38a-518a. - Mandatory coverage for hypodermic needles and syringes.
Section 38a-518b. - Coverage for certain off-label drug prescriptions.
Section 38a-518d. - Mandatory coverage for diabetes screening, testing and treatment.
Section 38a-518e. - Mandatory coverage for diabetes outpatient self-management training.
Section 38a-518f. - Mandatory coverage for certain prescription drugs removed from formulary.
Section 38a-518g. - Mandatory coverage for prostate cancer screening and treatment.
Section 38a-518h. - Mandatory coverage for certain Lyme disease treatments.
Section 38a-518i. - Mandatory coverage for pain management.
Section 38a-518j. - Mandatory coverage for ostomy-related supplies.
Section 38a-518k. - Mandatory coverage for colorectal cancer screening.
Section 38a-518l. - Mandatory coverage for certain renewals of prescription eye drops.
Section 38a-518m. - Mandatory coverage for certain wound-care supplies.
Section 38a-518o. - Mandatory coverage for bone marrow testing.
Section 38a-518p. - Mandating coverage for medically monitored inpatient detoxification.
Section 38a-518q. - Mandatory coverage for essential health benefits.
Section 38a-518t. - Mandatory coverage for prosthetic devices.
Section 38a-518u. - Coverage for psychotropic drugs. Standards re availability.
Section 38a-521. - Home health care by recognized nonmedical systems.
Section 38a-522. - Medicare supplement policies. Coverage of home health aide service.
Section 38a-524. - Coverage for occupational therapy.
Section 38a-525a. - Prior authorization prohibited for certain 9-1-1 emergency calls.
Section 38a-525b. - Mandatory coverage for mobile field hospital.
Section 38a-526. - Coverage for services of physician assistants and certain nurses.
Section 38a-530a. - Mandatory coverage for breast cancer survivors.
Section 38a-530b. - Carriers to permit direct access to obstetrician-gynecologist.
Section 38a-530e. - Mandatory coverage for contraceptives and sterilization.
Section 38a-530g. - Mandatory coverage for ovarian cancer screening and monitoring.
Section 38a-534. - Coverage for services performed by chiropractors.
Section 38a-536. - Mandatory coverage for infertility diagnosis and treatment. Limitations.
Section 38a-542a. - Coverage for routine patient care costs associated with certain clinical trials.
Section 38a-542b. - Clinical trial criteria.
Section 38a-542d. - Clinical trials: Routine patient care costs.
Section 38a-542e. - Clinical trials: Billing. Payments.
Section 38a-542g. - Clinical trials: Submission and certification of policy forms.
Section 38a-543. (Formerly Sec. 38-262j). - Reduction of payments on basis of Medicare eligibility.
Section 38a-544. - Prescription drug coverage. Mail order pharmacies. Step therapy use.
Section 38a-544a. - Prescription drug coverage. Synchronized refills.
Section 38a-549. - Coverage for adopted children.
Section 38a-550. - Copayments re in-network imaging services.
Section 38a-551. (Formerly Sec. 38-371). - Definitions.
Section 38a-552. (Formerly Sec. 38-372). - Provision of service to certain low-income individuals.
Section 38a-556a. - Connecticut Clearinghouse.
Section 38a-558. (Formerly Sec. 38-380). - Office of Health Care Access.
Section 38a-560. - Small employer grouping for health insurance coverage.
Section 38a-564. - Definitions.
Section 38a-565. - Special health care plans.
Section 38a-567. - Provisions of small employer plans and arrangements.
Section 38a-569. - Connecticut Small Employer Health Reinsurance Pool.
Section 38a-573. - Validity of separate provisions.
Section 38a-574. - Standard family health statement.
Section 38a-577. (Formerly Sec. 38-174ii). - Consumer dental health plans. Definitions.
Section 38a-578. (Formerly Sec. 38-174jj). - Certificate of authority. Application requirements.
Section 38a-580. (Formerly Sec. 38-174ll). - General surplus required.
Section 38a-584. (Formerly Sec. 38-174pp). - Complaint system.
Section 38a-588. (Formerly Sec. 38-174tt). - Penalty. Insolvency.
Section 38a-589. (Formerly Sec. 38-174uu). - Confidentiality.
Section 38a-590. (Formerly Sec. 38-174vv). - Commissioner's power to adopt regulations.
Section 38a-591. - Compliance with the Patient Protection and Affordable Care Act. Regulations.
Section 38a-591a. - Definitions.
Section 38a-591b. - Health carrier responsibilities re utilization review.
Section 38a-591c. - Utilization review criteria and procedures.
Section 38a-591g. - External reviews and expedited external reviews.
Section 38a-591h. - Record-keeping requirements. Report to commissioner upon request.
Section 38a-591i. - Regulations.
Section 38a-591k. - Violations. Notice and hearing. Penalties. Appeal.