(a) An agreement issued by a health care center governed by sections 38a-175 to 38a-194, inclusive, may be issued for health care or the costs thereof to a subscriber, to a subscriber and spouse, to a subscriber and family, to a subscriber and dependent or dependents related by blood, marriage or adoption or to a subscriber and ward. Such agreement or evidence of coverage document shall be in writing and a copy thereof furnished to the group contract holder or individual contract holder, as appropriate.
(b) Each such agreement shall contain the following provisions: (1) Name and address of the health care center; (2) eligibility requirements; (3) a statement of copayments, deductibles or other out-of-pocket expenses payment payable by the subscriber; (4) a statement of the nature of the health care services or benefits to be furnished and the period during which they will be furnished, and, if there are any services or benefits to be excepted, a detailed statement of such exceptions, provided such services or benefits to be furnished conform at a minimum to the requirements of the Federal Health Maintenance Organization Act; (5) a statement of terms and conditions upon which the agreement may be cancelled or otherwise terminated at the option of either party; (6) claims procedures; (7) enrollee grievance procedures; (8) continuation of coverage; (9) conversion; (10) extension of benefits, if any; (11) subrogation, if any; (12) description of the service area, out-of-area benefits and services, if any; (13) a statement of the amount payable to the health care center by the subscriber and by others on the subscriber's behalf and the manner in which such amount is payable; (14) a statement that the agreement includes the endorsement thereon and attached papers, if any, and contains the entire agreement; (15) a statement that no statement by the subscriber in the subscriber's application for an agreement shall void the agreement or be used in any legal proceeding thereunder, unless such application or an exact copy thereof is included in or attached to such agreement; and (16) a statement of the period of grace which will be allowed the subscriber for making any payment due under the agreement, which period shall not be less than ten days.
(c) Every subscriber shall receive an evidence of coverage from the group contract holder or the health care center. The evidence of coverage shall not contain provisions or statements which are unfair, inequitable, misleading, deceptive or which encourage misrepresentation. The evidence of coverage shall contain a clear statement of the provisions set forth in subdivisions (1) to (12), inclusive, of subsection (b) of this section.
(1971, P.A. 445, S. 10; P.A. 82-415, S. 6, 18; P.A. 90-68, S. 6, 16; P.A. 17-198, S. 21; P.A. 18-68, S. 3.)
History: P.A. 82-415 provided that services or benefits furnished to subscribers must conform to federal law requirements in Subdiv. (b) and substituted “health care center” for “corporation”; P.A. 90-68 divided section into Subsecs., made various technical corrections, outlined the provisions required for health care agreements and added Subsec. (c) re guidelines for the subscriber's evidence of coverage; Sec. 33-179j transferred to Sec. 38a-182 in 1991; P.A. 17-198 amended Subsec. (a) by replacing reference to Sec. 38a-192 with reference to Sec. 38a-194, effective July 1, 2017; P.A. 18-68 made technical changes in Subsec. (b).