Sec. 38a-214. (Formerly Sec. 33-168). Definition. Powers. Exemption from insurance laws. Reserves.

(a) A nonprofit medical service corporation is defined as a non-profit-sharing corporation without capital stock organized under the laws of the state for the purpose of establishing, maintaining and operating a plan whereby comprehensive health care, that includes inpatient and outpatient hospital care and home care, provided and billed by an approved general, special or chronic disease hospital, an approved clinic or an approved chronic and convalescent nursing home and services incidental thereto may be provided, at the expense of said corporation, to subscribers to such plan under a contract entitling such subscribers to the benefits provided therein. When so determined by any such corporation, comprehensive health care shall also include appliances, drugs, medicines, supplies and all other health goods and services, including the services of physicians, doctors of dentistry and other licensed practitioners of the healing arts. Any such corporation that provides coverage for the services of physicians shall also provide coverage for the services of chiropractors licensed under chapter 372 and naturopaths licensed under chapter 373. Each such corporation shall, except as otherwise provided in this title, be exempt from the provisions of the general statutes relating to insurance. The provisions of sections 38a-815 to 38a-819, inclusive, except subdivision (9) of section 38a-816, shall be applicable to such corporation. Such hospitals, clinics and chronic and convalescent nursing homes as shall be contained in a list of approved institutions maintained by the Department of Public Health shall be deemed approved for the purposes of sections 38a-214 to 38a-225, inclusive.

(b) A medical service corporation providing health care benefits to plan subscribers under the provisions of subsection (a) of this section may, upon obtaining the approval of the Insurance Commissioner as provided in section 38a-218: (1) Contract for the coordination of benefits with other hospital service corporations, medical service corporations or insurance companies to avoid duplication of benefits to be provided to its group subscribers; (2) make loans, grants or provide anything of value to a health care center covering all or part of the cost of health services provided to members; (3) contract with a health care center to provide insurance or similar protection to cover the cost of care provided through health care centers and to provide coverage in the event of the insolvency of the health care center; and (4) establish, maintain, own and operate health care centers as a line of business, provided (A) aggregate investments hereafter made by such corporation shall not exceed ten per cent of such corporation's contingency reserve as of the date of the investment; (B) such investments shall not be repaid or recovered from rates charged by such corporation for its non-health-care-center lines of business; and (C) the commissioner finds, based upon evidence furnished by such corporation, that the financial condition of such corporation and the rates of its non-health-care-center subscribers are not unduly jeopardized by such investment. Subdivision (1) of this subsection shall be subject to such regulations as may be adopted by the Insurance Commissioner, in accordance with the provisions of chapter 54, to establish coordination of benefits clauses in health care benefit contracts.

(c) Each medical service corporation shall maintain reserves equal in amount to its liabilities under all its policy contracts, as the same are computed in accordance with regulations adopted in accordance with the provisions of chapter 54 upon reasonable consideration of ascertained experience for the purpose of adequately protecting the subscriber or securing the solvency of such company. Each such corporation shall maintain a reserve for contingencies that shall not be less than the amount required by companies licensed to transact accident and health insurance, under section 38a-72. The commissioner may adopt regulations, in accordance with the provisions of chapter 54, prescribing the maximum amount that may be held in the reserve for contingencies, and in adopting such regulations, shall consider the stability, solvency and interests of the corporation, and the interests of the subscribers and other affected persons. On and after October 1, 1974, the commissioner may require a medical service corporation to adjust its reserve for contingencies to comply with the provisions of this section and to adjust its rates or benefits or both to reflect such adjustment in the reserve for contingencies.

(1949 Rev., S. 5282; 1951, 1953, S. 2597d; 1957, P.A. 407; 1963, P.A. 333; 1967, P.A. 775; 1969, P.A. 342; 686, S. 4; 1971, P.A. 587; P.A. 74-5, S. 2; P.A. 75-50; P.A. 77-614, S. 163, 323, 610; P.A. 80-482, S. 220, 348; P.A. 81-101, S. 3; P.A. 82-415, S. 13, 18; P.A. 83-216, S. 2; P.A. 93-381, S. 9, 39; P.A. 95-257, S. 12, 21, 58; P.A. 14-235, S. 17; P.A. 15-118, S. 66; 15-247, S. 4; P.A. 17-15, S. 14.)

History: 1963 act authorized payments by nonprofit medical service corporation to chiropractors; 1967 act defined “medical services” as professional services performed by physicians and other health services and supplies, except prescription drugs and services covered as hospital services where previously term was “not to be construed to include hospital services”; 1969 act replaced “medical services” and definition of such services with “comprehensive health care” and provisions specifying what is included in such services, added provision re list of approved institutions and added Subsec. (b); 1971 act specified that corporations providing coverage for physicians' services shall also provide for chiropractors' services; P.A. 74-5 added Subsec. (c); P.A. 75-50 required that corporations providing coverage for physicians' services also provide coverage for naturopaths' services and referred to chiropractors licensed under chapter 372 rather than under Sec. 20-27; P.A. 77-614 made insurance department a division within the department of business regulation with commissioner as its head and replaced department of health with department of health services, effective January 1, 1979; P.A. 80-482 restored insurance division as independent department with commissioner as its head and abolished department of business regulation; P.A. 81-101 required that the unfair insurance practice provisions (Secs. 38-60 to 38-64) be applicable to medical service corporations; P.A. 82-415 added Subsec. (b)(3) and (4), empowering medical service corporations to make loans, etc. to health care centers and to contract with such centers to provide insurance; P.A. 83-216 amended Subsec. (b) to allow medical service corporations to own, operate and maintain health care centers as a line of business; Sec. 33-168 transferred to Sec. 38a-214 in 1991; P.A. 93-381 replaced department of health services with department of public health and addiction services, effective July 1, 1993; P.A. 95-257 replaced Commissioner and Department of Public Health and Addiction Services with Commissioner and Department of Public Health, effective July 1, 1995; P.A. 14-235 amended Subsec. (b) to replace reference to Sec. 38a-488 with reference to Sec. 38a-218 and make technical changes; P.A. 15-118 amended Subsec. (a) to replace “specifically designated herein” with “otherwise provided in this title”; P.A. 15-247 amended Subsec. (a) by replacing “specifically designated herein” with “otherwise provided in this title”, amended Subsec. (b) by deleting former Subdiv. (1) re adjustment of rates based on past and prospective loss experience and classification of subscribers, redesignating existing Subdivs. (2) to (5) as Subdivs. (1) to (4), adding reference to Ch. 54 and deleting reference to eligibility guidelines, amended Subsec. (c) by adding references to Ch. 54 and deleting provision re reasonable time period for compliance, and made technical and conforming changes, effective July 10, 2015; P.A. 17-15 made technical changes in Subsecs. (b)(4) and (c).

Notation

See Sec. 38a-504 re insurance policy or contract requirements covering surgical removal of tumors and treatment of leukemia.

Annotations to former section 33-168:

Cited. 184 C. 352.

Cited. 29 CS 474.