3.1 Connecticut Health Insurance Policy Requirements

Who Regulates Health Insurance in Connecticut

The Connecticut Insurance Department (CID) licenses producers, approves accident and sickness (health) policy forms and rate filings, and enforces Title 38a of the Connecticut General Statutes. Producers schedule through Pearson VUE; the combined Life, Accident & Health or Sickness exam is code 12-CT-03 -- 80 scored questions, a 2.5-hour limit, and a 70% passing score. About 30 of those scored items test Connecticut-specific statutes (split across the common-regulation and health-law outlines), so expect roughly 7-8 questions to track the health-law rules in this chapter.

Three agencies share the health space, and the exam tests which one owns each function:

Trap: complaints about a claim denial go to CID Consumer Affairs; questions about Medicaid eligibility go to DSS. The exam writes distractors that swap them.

The 10-Day Free Look

Every individual health (accident and sickness) policy delivered in Connecticut must carry a 10-day free look ("right to examine"). The clock starts on delivery of the contract, not the application date. If the insured returns it within 10 days, the insurer must refund 100% of premium paid and treat the policy as void from issue.

• Applies to individual accident and sickness policies.
• It matches the 10-day life-insurance free look in Connecticut -- a deliberate exam overlap.
• Long-term care policies get 30 days instead (covered in 3.3) -- the single most-missed distractor.

Mandatory Uniform Policy Provisions

Connecticut adopts the NAIC Uniform Individual Accident and Sickness Policy Provisions (UPPL). Memorize these numbers:

Worked example: A claimant is hurt March 1, files notice March 12 (within 20 days), and the insurer mails a claim form March 30. Because the form arrived 15+ days after notice and none was furnished, the insured may submit proof in any written form and the deadline still runs 90 days from the loss.

Access Health CT and the ACA Floor

Access Health CT (AHCT) is Connecticut's state-based marketplace -- the only channel through which residents receive advance premium tax credits and cost-sharing reductions. A plan bought directly from a carrier outside AHCT is legal but forfeits the subsidy.

• Open enrollment: November 1 - January 15.
• Special enrollment periods (SEPs): triggered by qualifying life events (loss of coverage, marriage, birth, move).
• Plans sit in four metal tiers -- Bronze (~60% actuarial value), Silver (~70%), Gold (~80%), Platinum (~90%).
• Subsidy size is set by household income relative to the federal poverty level (FPL).

Essential Health Benefits and State Mandates

Individual and small-group ACA plans must cover all ten essential health benefits (EHBs):

1. Ambulatory (outpatient) services
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance use disorder services
6. Prescription drugs
7. Rehabilitative and habilitative services and devices
8. Laboratory services
9. Preventive, wellness, and chronic-disease management
10. Pediatric services, including oral and vision care

Connecticut layers on state-mandated benefits (for example colorectal and mammography screening and certain infertility coverage) and enforces mental health parity -- a plan may not impose worse copays, deductibles, day limits, or prior-authorization rules on mental health and substance use care than on comparable medical care.

Pre-Existing Conditions and Prompt Pay

ACA-compliant plans cannot exclude or rate up pre-existing conditions. Short-term limited-duration plans are the exception and may still apply exclusions -- a favorite exam distinction.

Connecticut's prompt-pay rule (CGS Sec. 38a-816(15)) is heavily tested. A clean claim -- one containing all information necessary for payment -- must be paid within 45 days, or the insurer owes 15% annual interest on the amount due. If the claim is deficient, the insurer has 30 days to request the missing information and then 30 more days after receiving it to pay without interest.

Trap: the trigger for interest is the 45-day clean-claim deadline and a 15% rate, not a 30-day or 60-day figure -- older study text using "30-day decision / 45-day payment" stages is wrong for the interest rule.

HUSKY Health (Medicaid)

Connecticut Medicaid is branded HUSKY Health, run by DSS, not CID:

• HUSKY A -- children, parents/caretakers, pregnant women
• HUSKY B -- CHIP for children in higher-income families
• HUSKY C -- aged, blind, and disabled adults
• HUSKY D -- low-income adults under Medicaid expansion