(a) Enrollment period. In the event of an insolvency of a health care center, upon order of the commissioner, all other carriers that participated in the enrollment process with the insolvent health care center at a group's last regular enrollment period shall offer such group's subscribers of the insolvent health care center a thirty-day enrollment period commencing upon the date of insolvency. Each carrier shall offer such subscribers of the insolvent health care center the same coverages and rates that such carrier had offered to the subscribers of the group at its last regular enrollment period for the remainder of the term of the original group contract. An open enrollment shall not be required where the group contract holder participates in a self-insured, self-funded or other health plan exempt from the regulation of the commissioner, unless the plan administrator and group contract holder voluntarily agree to offer a simultaneous open enrollment and extend coverage under the same enrollment terms and conditions as are applicable to carriers under sections 38a-175 to 38a-183, inclusive, section 38a-192 and the regulations adopted under said sections.
(b) Replacement coverage allocated among centers within service area. If no other carrier has been offered to one or more groups enrolled in the insolvent health care center, or if the commissioner determines that the other carrier or carriers lack sufficient health care delivery resources to assure that health care services will be available and accessible to all of the group enrollees of the insolvent health care center, the commissioner shall allocate equitably the insolvent health care center's group contracts for such groups among all health care centers that operate within a portion of the insolvent health care center's service area, taking into consideration the health care delivery resources of each health care center. Each health care center, to which a group or groups are so allocated, shall offer such group or groups the health care center's existing coverage that is most similar to the group's coverage with the insolvent health care center at rates determined in accordance with the successor health care center's existing rating methodology. No offering by a carrier shall be required where the group contract holder participates in a self-insured, self-funded or other health plan exempt from regulation by the commissioner. The commissioner shall also allocate equitably the insolvent health care center's nongroup enrollees who are unable to obtain other coverage among all health care centers that operate within a portion of the insolvent health care center's service area, taking into consideration the health care delivery resources of each such health care center. Each health care center to which nongroup enrollees are allocated shall offer each such nongroup enrollee the health care center's existing coverage for individual coverage as determined by such nongroup enrollee's type of coverage in the insolvent health care center at rates determined in accordance with the successor health care center's existing rating methodology. Successor health care centers that do not offer direct nongroup enrollment may aggregate all of the allocated nongroup enrollees into one group for rating and coverage purposes.
(c) Replacement coverage extended to all subscribers. Exception. (1) As used in this subsection, “discontinuance” means the termination of the contract between the group contract holder and a health care center due to the insolvency of the health care center, and does not refer to the termination of any agreement between any individual enrollee and the health care center.
(2) Any carrier providing replacement coverage with respect to group hospital, medical or surgical expense or service benefits within a period of sixty days from the date of discontinuance of a prior health care center contract or policy providing such hospital, medical or surgical expense or service benefits shall immediately cover all subscribers and subscribers' beneficiaries who were validly covered under the previous health care center contract or policy at the date of discontinuance and who would otherwise be eligible for coverage under the succeeding carrier's contract, regardless of any provisions of the contract relating to active employment or hospital confinement or pregnancy.
(3) Except to the extent benefits for the condition would have been reduced or excluded under the prior carrier's contract or policy, no provision in a succeeding carrier's contract of replacement coverage which would operate to reduce or exclude benefits on the basis that the condition giving rise to benefits, preexisted the effective date of the succeeding carrier's contract, shall be applied with respect to those subscribers and subscribers' beneficiaries validly covered under the prior carrier's contract or policy on the date of discontinuance.
(d) Insolvency. Priority of distribution. In the event of the insolvency of a health care center, for purposes of determining the priority of distribution of the general assets of the health care center, claims of enrollees, enrollees' beneficiaries, subscribers and subscribers' beneficiaries shall have the same priority as established by section 38a-944 for policyholders and beneficiaries of insureds of insurance companies described in subdivision (3) of subsection (a) of section 38a-944. If an enrollee or subscriber is liable to any provider for services provided pursuant to and covered by the health care center, that liability shall have the status of an enrollee or subscriber claim for distribution of assets. Any provider who is obligated by statute or agreement to hold enrollees or subscribers harmless from liability for services provided pursuant to and covered by a health care center shall have a priority of distribution of the general assets immediately following that of enrollees, enrollees' beneficiaries, subscribers and subscribers' beneficiaries as described in this subsection, and immediately preceding the priority of distribution described in subdivision (4) of subsection (a) of section 38a-944.
(P.A. 90-68, S. 14, 16; P.A. 99-9, S. 5, 6; P.A. 14-122, S. 166; P.A. 17-15, S. 12.)
History: P.A. 99-9 substituted “subscribers” for “enrollees” in Subsec. (a), substituted “subscribers and subscribers' beneficiaries” for “enrollees” in Subsec. (c) and added new Subsec. (d) re priority of distribution in the event of insolvency, effective May 12, 1999; P.A. 14-122 made a technical change in Subsec. (c)(1); P.A. 17-15 amended Subsec. (a) to replace “38a-178, inclusive, subsection (a) of section 38a-179, sections 38a-182 to 38a-185, inclusive, 38a-187, 38a-188 and 38a-192 to 38a-194, inclusive,” with “38a-183, inclusive, section 38a-192”, and made technical changes.