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Group Health Insurance Laws

Connecticut Health Insurance Laws

This page describes the protections that you have in group health plans, such as those offered by employers or labor unions. Your protections will vary somewhat, depending on whether your plan is a fully insured group health plan or a self-insured group health plan.  The plan’s benefits information must indicate whether the plan is self-insured.

 

EMPLOYER MANDATE

Under health reform, an insurance law is in place for employers, requiring large businesses to offer coverage to each of their full-time or full-time equivalent (30 hours per week) workers. While there aren’t many requirements for the benefits employers must provide in the group plans they choose, plans must have an actuarial value of at least 60 percent and cover preventive care. Your employer may also offer a voucher for coverage on Access Health CT, the health insurance exchange, that is equivalent in value to plans they are offering to employees.
WHEN DOES A GROUP HEALTH PLAN HAVE TO LET ME IN?
• In general, you have to be eligible for the group health plan.  For example, your employer may not give health benefits to all employees.  Or, your employer may offer an HMO plan that you cannot join because you live outside of the plan’s service area.

• You cannot be turned away or charged more because of your health status.  Health status means your medical condition or history, genetic information or disability. This protection is called nondiscrimination.  Employers may refuse or restrict coverage for other reasons (such as part time employment), as long as these are unrelated to health status and applied consistently.  However, if you work for a small employer in Connecticut, insurance companies must offer coverage to all eligible employees. Discrimination due to health status is not permitted

The Acme Company has 200 employees and offers two different health plans. Full time employees are offered a high option plan that covers prescription drugs; part time employees are offered a low option plan that does not.  This is permitted under the law. By contrast, in a cost-cutting move, Acme restricts its high option plan to those employees who can pass a physical examination.  This is not permitted under the law.

• You must be given a special opportunity to sign up for your group health plan if certain changes happen to your family.  In addition to any regular enrollment period your employer or group health plan offers, you must be offered a special opportunity to enroll in your group health plan after certain events. Depending on the event, these special enrollment periods can last either 30 or 60 days. You can elect coverage at this time.  If your group plan offers family coverage, your dependents can elect coverage as well.  Enrollment during a special enrollment period is not considered late enrollment. Certain changes can trigger a 30-day special enrollment opportunity

• The birth, adoption, or placement for adoption of a child

• Marriage

• Involuntary loss of other coverage (for example, that you or your dependents had through yourself or another family member and lost because of death, divorce, legal separation, termination, retirement, or reduction in hours worked)

Certain changes can trigger a 60-day special enrollment opportunity

• Loss of eligibility under Medicaid or SCHIP

• Eligibility for a state Medicaid or SCHIP premium assistance subsidy applicable to premiums a group plan

• Under Connecticut law, newborns and adopted children are automatically covered under the parents’ fully insured health plan, if that plan provides dependent coverage. The insurer may require that the parent enroll the child within the 31 days in order to continue coverage beyond the 31 days.

• If you have a disabled child, that child may remain covered under your fully insured group health plan after he or she reaches the age at which dependent coverage is usually terminated.  To qualify, your adult son or daughter must be incapable of self-support because of mental or physical disability and must be chiefly dependent on the policyholder for support.  Proof of incapacity must be furnished within 31 days of reaching the time limit and may be required periodically thereafter.

• If your group health plan covers dependents, you may be able to keep your son or daughter covered under the plan after the age of majority.  Most group health plans will allow your son or daughter to remain covered under your family plan past the age of 19 if they are a full time student.   If your child is in college and covered as a dependent under your group plan, but cannot maintain student status due to illness, he or she may still be able to remain covered as your dependent for up to one year. A new federal law allows dependent children who take a medically necessary leave of absence due to a serious illness or injury to remain covered as dependents under their parents’ group plan for up to one year or until the coverage would otherwise end, whichever comes first. This law will apply to plan years beginning on or after October 9, 2009. For more information about this important protection, contact the U.S. Department of Labor at (866) 444-EBSA (3272).
In addition, in Connecticut, fully insured group health plans must cover dependents up to the age of 26 if they meet other qualifications.  To remain covered as a dependent to this age, your child must be unmarried, a resident of Connecticut (except no residency requirement for dependents under the age of 19 years of age or full-time students), and not enrolled in a group health plan through his or her own job. This law does not apply to self-insured group health plans.  Check with your employer to find out the kind of group health plan you have. For more information on this topic contact the Connecticut Insurance Department or check out this fact sheet at http://www.ct.gov/cid/lib/cid/BullHC71rev.pdf.
Read you plan documents carefully to determine when your child will “age off” your group health plan.

• When you begin a new job, your employer may require a waiting period before you can sign up for health coverage.  These waiting periods, however, must be applied consistently and cannot vary due to your health status.   You will not have health insurance coverage during this time.

• When you begin a new job with health insurance through an HMO, the HMO may require an affiliation period before coverage begins.  During this affiliation period, you will not have health insurance coverage. The HMO also cannot impose any pre-existing condition exclusions if it imposes an affiliation period.  An HMO affiliation period cannot exceed 2 months (3 months for late enrollees), and you cannot be charged a premium during this time.

• If you have to take leave from your job due to illness, the birth or adoption of a child, or to care for a seriously ill family member, you may be able to keep your group health coverage for a limited time.  A federal law known as the Family and Medical Leave Act (FMLA) guarantees you up to 12 weeks of job-protected leave in these circumstances.   The FMLA applies to you if you work at a company with 50 or more employees.
If you qualify for leave under FMLA, your employer must continue your health benefits.  You will have to continue paying your share of the premium.
If you decide not to return to work at the end of the leave period, your employer may require you to pay back the employer’s share of the health insurance premium.  However, if you don’t return to work because of factors outside your control (such as a need to continue caring for a sick family member, or because your spouse is transferred to a job in a distant city) you will not have to repay the premium.
For more information about your rights under FMLA, contact the U.S. Department of Labor.

• In addition, Connecticut has a state FMLA law that is similar to federal law.  For more information contact the Connecticut Department of Labor, Division of Wage and Workplace Standards at (860) 263-6000 or visit them online at http://www.ctdol.state.ct.us/wgwkstnd/wgemenu.htm.

CAN A GROUP HEALTH PLAN LIMIT MY COVERAGE FOR PRE-EXISTING CONDITIONS?
When you first enroll in a group health plan, the employer or insurance company may ask if you have any pre-existing conditions.  Or, if you make a claim during the first twelve months of coverage, the plan may look back to see whether it was for such a condition.  If so, it may try to exclude coverage for services related to that condition for a certain length of time.  However, federal and state laws protect you by placing limits on these pre-existing condition exclusion periods under group health plans. In some cases your protections will vary, depending on the type of group health plan.
• A group health plan can as apply a pre-existing condition exclusion period only to those conditions for which you actually received (or were recommended to receive) a diagnosis, treatment or medical advice within the 6 months immediately before you joined that plan.  The plan cannot count as diagnosis, treatment or medical advice routine follow-up care to determine if breast cancer has reoccurred in a person who is breast cancer free unless evidence of breast cancer is found as a result of the follow-up.  This period is also called the look back period.

• Group health plans cannot apply a pre-existing condition exclusion period for pregnancy, newborns or newly adopted children, children placed for adoption, or genetic information.

• Group health plans can only exclude covering for pre-existing conditions for a limited time.  The maximum period is 12 months if you are in a group health plan.  However, if you enroll late in a group health plan (after you were hired and not during a regular or special enrollment period) under a self-insured group health plan, you may have a pre-existing condition exclusion period of up to 18 months.

• Group plans that imposed pre-existing condition exclusion periods must give you credit for any previous continuous creditable coverage that you’ve had.  Most types of private and government sponsored health coverage is considered creditable coverage.

• Determining if coverage is continuous, depends on the type of plan you are joining. Generally for fully-insured group health plans, coverage counts as continuous if it is not interrupted by a break of 120 or more days in a row.  If you lost your job involuntarily, you can be uninsured for a somewhat longer time – 150 days – and still have your prior coverage counted as continuous when you join a new fully insured group health plan. For self-insured group health plans, coverage counts as continuous if it is not interrupted by a break of 63 or more days in a row.  What is creditable coverage?

Most health insurance counts as creditable coverage, including:

Children’s Health Insurance Program  Medicare
Federal Employees Health Benefits (FEHBP) Military health coverage
Foreign National Coverage     (CHAMPUS, TRICARE)
Group health plan (including COBRA) State high-risk pools
Indian Health Service  Student health insurance
Individual health insurance VA coverage
Medicaid

In most cases, you should get a certificate of creditable coverage when you leave a health plan.  You also can request certificates at other times.  If you cannot get one, you can submit other proof of prior coverage, such as old health plan ID cards or statements from your doctor showing bills paid by your health insurance plan.
In determining continuous coverage, employer-imposed waiting periods and HMO affiliation periods do not count as a break in coverage.  If your new plan imposes a pre-existing condition exclusion period, you can credit time under your prior continuous coverage toward it.  If your employer requires a waiting period, the pre-existing condition exclusion period begins on the first day of the waiting period. HMOs that require an affiliation period cannot exclude coverage for pre-existing conditions.
What is continuous coverage?

Fully insured and self-insured group health plans count continuous coverage differently.

Art, who is diabetic, worked for the Ajax Company and was covered under its group health plan for 18 months.  He lost his job and was without coverage for 100 days. Fortunately, on the 100th day after leaving Ajax, Art found a new job at Beta Corporation.  He enrolled immediately in Beta’s fully insured group health plan, which cover care for diabetes but requires a pre-existing condition exclusion period.  In Connecticut fully insured group health plans count as continuous all creditable coverage that is not interrupted by a lapse of 120 or more consecutive days.  Therefore, because Art’s lapse in coverage was less than 120 days, he will get credit for his coverage at Ajax.  Beta’s plan will begin paying for Art’s diabetes care immediately.

Now consider a slightly different situation.  Assume Beta Corporation’s group health plan is self-insured.  Self-insured plans must count as continuous all creditable coverage that is not interrupted by a break of 63 or more consecutive days.  In this case, Art will not get credit for his prior coverage at Ajax because it was followed by a break greater than 63 days.  Beta’s plan will begin paying for Art’s diabetes care at the end of the exclusion period.

• Your protections may differ if you move to a self-insured group health plan that offers more benefits than your old one did. Self-insured plans can look back to determine whether your previous health plan covered prescription drugs, mental health, substance abuse, dental care, or vision care.  If you did not have continuous coverage for one or more of these categories of benefits, your new group health plan may impose a pre-existing condition exclusion period for that category.  Even if coverage is continuous, there may be an exclusion for certain benefits:

Sue needs prescription medication to control her blood pressure.  She had 2 years of continuous coverage under her employer’s group health plan, which did not cover prescription drugs.  Sue changes jobs, and her new employer’s self-insured plan does cover prescription drugs.  However, because her prior policy did not, the new plan refuses to cover her blood pressure medicine for 6 months.

Question: Is this permitted?

Answer: Yes.  However, the plan must pay for covered doctor visits, hospital care, and other services for Sue’s high blood pressure.  It also must pay for covered prescription drugs she needs for other conditions that were not pre-existing.

• No pre-existing condition exclusion period can be applied without appropriate notice. Your group health plan must inform you, in writing, if it intends to impose such a period.  Also, if needed, it must help you get a certificate of creditable coverage from your old health plan.

LIMITS TO PROTECTIONS FOR CERTAIN GOVERNMENT WORKERS
Federal law permits state, county, and local governments to exempt their employees in self-insured group health plans from some of the protections discussed previously in this chapter.  Public employers must make this choice annually.  When they do so, they are required to notify the federal government and specify which health insurance protections will not apply to their employees’ group health plan.
In the past, a large number of public employers in Connecticut have decided that certain health insurance protections will not apply to their employees.  The Center for Medicare and Medicaid Services (CMS) used to post a list of employers which had elected to exempt, however it has removed this information from its web site.
If you are not sure about your protections under your public employee health plan, you should contact your employer.  In addition, you can contact CMS directly at (877) 267-2323 ext. 61565 or at (410) 786-1565 to see if your employer has elected to be exempt from certain protection.
AS YOU ARE LEAVING GROUP COVERAGE…
• If you are leaving your job or otherwise losing access to your group health coverage, you may be able to remain covered under the group health plan for a limited time.  In addition, you may have special protections when buying certain kinds of individual health insurance coverage.  See Chapter 3 for more information about COBRA and state continuation coverage, conversion, and the Connecticut Health Reinsurance Association.

• If you have lost your group health coverage and are receiving benefits from the Trade Adjustment Assistance (TAA) program, you may be eligible for a federal income tax credit to help you pay for new health coverage.  This credit is called the Health Coverage Tax Credit (HCTC), and is equal to 80% of the cost of qualified health coverage, including COBRA, state continuation coverage, and coverage through the Connecticut Health Reinsurance Association (HRA). (see Chapter 5)

• If you are a retiree aged 55-65 and are receiving pension benefits from the Pension Benefit Guaranty Corporation, you may also be eligible for the HCTC. (see Chapter 5)

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