AN ACT CONCERNING HEALTH COVERAGE MANDATES FOR CERTAIN HEALTH CONDITIONS.

Substitute House Bill No. 5374

Public Act No. 26-33

AN ACT CONCERNING HEALTH COVERAGE MANDATES FOR
CERTAIN HEALTH CONDITIONS.
Be it enacted by the Senate and House of Representatives in General
Assembly convened:

Section 1. Section 38a -1 of the general statutes is repealed and the
following is substituted in lieu thereof (Effective January 1, 2027):
Terms used in this title and sections 2 to 5, inclusive, of this act, unless
it appears from the context to the contrary, shall have a scope and
meaning as set forth in this section.
(1) "Affiliate" or "affiliated" means a person that directly, or indirectly
through one or more intermediaries, controls, is controlled by or is
under common control with another person.
(2) "Alien insurer" means any insurer that has been chartered by or
organized or constituted within or under the laws of any jurisdiction or
country without the United States.
(3) "Annuities" means all agreements to make periodical payments
where the making or continuance of all or some of the series of the
payments, or the amount of the payment, is dependent upon the
continuance of human life or is for a specified term of years. Th is
definition does not apply to payments made under a policy of life
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insurance.
(4) "Commissioner" means the Insurance Commissioner.
(5) "Control", "controlled by" or "under common control with" means
the possession, direct or indirect, of the power to direct or cause the
direction of the management and policies of a person, whether through
the ownership of voting securities, by contract other than a commercial
contract for goods or nonmanagement services, or otherwise, unless the
power is the result of an official position with the person.
(6) "Domestic insurer" means any insurer that has been chartered by,
incorporated, organized or constituted within or under the laws of this
state.
(7) "Domestic surplus lines insurer" means any domestic insurer that
has been authorized by the commissioner to write surplus lines
insurance.
(8) "Foreign country" means any jurisdiction not in any state, district
or territory of the United States.
(9) "Foreign insurer" means any insurer that has been chartered by or
organized or constituted within or under the laws of another state or a
territory of the United States.
(10) "Insolvency" or "insolvent" means, for any insurer, that it is
unable to pay its obligations when they are due, or when its admitted
assets do not exceed its liabilities plus the greater of: (A) Capital and
surplus required by law for its organization and continued operation;
or (B) the total par or stated value of its authorized and issued capital
stock. For purposes of this subdivision "liabilities" shall include but not
be limited to reserves required by statute or by regulations adopted by
the comm issioner in accordance with the provisions of chapter 54 or
specific requirements imposed by the commissioner upon a subject
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company at the time of admission or subsequent thereto.
(11) "Insurance" means any agreement to pay a sum of money,
provide services or any other thing of value on the happening of a
particular event or contingency or to provide indemnity for loss in
respect to a specified subject by specified perils in return for a
consideration. In any contract of insurance, an insured shall have an
interest which is subject to a risk of loss through destruction or
impairment of that interest, which risk is assumed by the insurer and
such assumption shall be part of a general scheme to distribute losses
among a large group of persons bearing similar risks in return for a
ratable contribution or other consideration.
(12) "Insurer" or "insurance company" includes any person or
combination of persons doing any kind or form of insurance business
other than a fraternal benefit society, and shall include a receiver of any
insurer when the context reasonably permits.
(13) "Insured" means a person to whom or for whose benefit an
insurer makes a promise in an insurance policy. The term includes
policyholders, subscribers, members and beneficiaries. This definition
applies only to the provisions of this title and does not defi ne the
meaning of this word as used in insurance policies or certificates.
(14) "Life insurance" means insurance on human lives and insurances
pertaining to or connected with human life. The business of life
insurance includes granting endowment benefits, granting additional
benefits in the event of death by accident or accidental means, granting
additional benefits in the event of the total and permanent disability of
the insured, and providing optional methods of settlement of proceeds.
Life insurance includes burial contracts to the extent provided by
section 38a-464.
(15) "Mutual insurer" means any insurer without capital stock, the
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managing directors or officers of which are elected by its members.
(16) "Person" means an individual, a corporation, a partnership, a
limited liability company, an association, a joint stock company, a
business trust, an unincorporated organization or other legal entity.
(17) "Policy" means any document, including attached endorsements
and riders, purporting to be an enforceable contract, which
memorializes in writing some or all of the terms of an insurance
contract.
(18) "State" means any state, district, or territory of the United States.
(19) "Subsidiary" of a specified person means an affiliate controlled
by the person directly, or indirectly through one or more intermediaries.
(20) "Unauthorized insurer" or "nonadmitted insurer" means an
insurer that has not been granted a certificate of authority by the
commissioner to transact the business of insurance in this state or an
insurer transacting business not authorized by a valid certificate.
(21) "United States" means the United States of America, its territories
and possessions, the Commonwealth of Puerto Rico and the District of
Columbia.
Sec. 2. (NEW) ( Effective January 1, 2027 ) Each individual health
insurance policy providing coverage of the type specified in
subdivisions (1), (2), (4), (11) and (12) of section 38a -469 of the general
statutes delivered, issued for delivery, renewed, amended or continued
in this state on or aft er January 1, 2027, shall provide coverage for the
treatment of Pediatric Autoimmune Neuropsychiatric Disorders
Associated with Streptococcal Infections and Pediatric Acute -onset
Neuropsychiatric Syndrome, including, but not limited to, the use of
intravenous immunoglobulin therapy.
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Sec. 3. (NEW) (Effective January 1, 2027) Each group health insurance
policy providing coverage of the type specified in subdivisions (1), (2),
(4), (11) and (12) of section 38a -469 of the general statutes delivered,
issued for delivery, renewed, amended or continued in this state on or
after Ja nuary 1, 2027, shall provide coverage for the treatment of
Pediatric Autoimmune Neuropsychiatric Disorders Associated with
Streptococcal Infections and Pediatric Acute -onset Neuropsychiatric
Syndrome, including, but not limited to, the use of intravenous
immunoglobulin therapy.
Sec. 4. (NEW) ( Effective January 1, 2027 ) (a) For the purposes of this
section, "scalp cooling system" means any device designed and intended
for repeated medical use to cool the human scalp to prevent or reduce
hair loss as a result of chemotherapy.
(b) (1) Each individual health insurance policy providing coverage of
the type specified in subdivisions (1), (2), (4), (11), (12) and (13) of section
38a-469 of the general statutes delivered, issued for delivery, renewed,
amended or continued in this sta te on or after January 1, 2027, that
provides coverage for chemotherapy shall provide coverage for scalp
cooling systems used in connection with such chemotherapy that is at
least equivalent to such coverage provided under Medicare.
(2) No policy described in subdivision (1) of this subsection shall
impose a coinsurance, copayment, deductible or other out -of-pocket
expense for any such scalp cooling system that is more restrictive than
that imposed on substantially all other benefits provided under such
policy, except that a high deductible health plan, as such term is used in
subsection (f) of section 38a -493 of the general statutes, shall not be
subject to the deductible limits set forth in this subdivision or under
Medicare pursuant to subdivision (1) of this subsection.
(c) Any individual health insurance policy may require prior
authorization for scalp cooling systems, provided such prior
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authorization is required in the same manner and to the same extent as
is required for other covered benefits under such policy.
Sec. 5. (NEW) ( Effective January 1, 2027 ) (a) For the purposes of this
section, "scalp cooling system" means any device designed and intended
for repeated medical use to cool the human scalp to prevent or reduce
hair loss as a result of chemotherapy.
(b) (1) Each group health insurance policy providing coverage of the
type specified in subdivisions (1), (2), (4), (11), (12) and (13) of section
38a-469 of the general statutes delivered, issued for delivery, renewed,
amended or continued in this state on or after January 1, 2027, that
provides coverage for chemotherapy shall provide coverage for scalp
cooling systems used in connection with such chemotherapy that is at
least equivalent to such coverage provided under Medicare.
(2) No policy described in subdivision (1) of this subsection shall
impose a coinsurance, copayment, deductible or other out -of-pocket
expense for any such scalp cooling system that is more restrictive than
that imposed on substantially all other benefits provided under such
policy, except that a high deductible health plan, as such term is used in
subsection (f) of section 38a -520 of the general statutes, shall not be
subject to the deductible limits set forth in this subdivision or under
Medicare pursuant to subdivision (1) of this subsection.
(c) Any group health insurance policy may require prior
authorization for scalp cooling systems, provided such prior
authorization is required in the same manner and to the same extent as
is required for other covered benefits under such policy.
Sec. 6. Subsection (a) of section 38a -492t of the general statutes is
repealed and the following is substituted in lieu thereof (Effective January
1, 2027):
(a) As used in this section, "prosthetic device" means an artificial limb
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device to replace, in whole or in part, an arm or a leg, including a device
that contains a microprocessor if such microprocessor-equipped device
is determined by the insured's or enrollee's health care provider to be
medically necessary. ["Prosthetic device" does not include a device that
is designed exclusively for athletic purposes.]
Sec. 7. Subsection (a) of section 38a -518t of the general statutes is
repealed and the following is substituted in lieu thereof (Effective January
1, 2027):
(a) As used in this section, "prosthetic device" means an artificial limb
device to replace, in whole or in part, an arm or a leg, including a device
that contains a microprocessor if such microprocessor-equipped device
is determined by the insured's or en rollee's health care provider to be
medically necessary. ["Prosthetic device" does not include a device that
is designed exclusively for athletic purposes.]
Sec. 8. Subsection (a) of section 38a -509 of the general statutes is
repealed and the following is substituted in lieu thereof (Effective January
1, 2027):
(a) Subject to the limitations set forth in subsection (b) of this section
and except as provided in subsection (c) of this section, each individual
health insurance policy providing coverage of the type specified in
subdivisions (1), (2), (4), (11) and (1 2) of section 38a -469 delivered,
issued for delivery, amended, renewed or continued in this state on or
after January 1, 2018, shall provide coverage for the medically necessary
expenses for the diagnosis and treatment of infertility, including, but not
limited to, ovulation induction, intrauterine insemination, in -vitro
fertilization, uterine embryo lavage, embryo transfer, gamete intra -
fallopian transfer, zygote intra -fallopian transfer and low tubal ovum
transfer. For purposes of this section, "infertility" means [the condition
of an individual who is unable to conceive or produce conception or
sustain a successful pregnancy during a one -year period or such
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treatment is medically necessary] (1) the inability to establish or carry a
pregnancy based on an individual's medical, sexual and reproductive
history, age, physical findings, diagnostic testing or any combination of
such factors, including, but not limited to, infertility arising from
disabilities or from medical treatments or conditions associated with a
disability, (2) the need for medical intervention, including, but not
limited to, the use of donor gametes, donor embryos or a gestational
surrogate, to establish a pregnancy either as an individual or with a
partner, (3) an individual's inability to establish a pregnancy or carry a
pregnancy to live birth after twelve months of unprotected sexual
intercourse when the individual and the individual's partner have the
necessary gametes to establish a pregnancy, provided a pr egnancy loss
shall not restart the twelve -month period, and (4) an individual's
inability to establish a pregnancy or to carry a pregnancy to live birth
after six months of unprotected se xual intercourse due to the
individual's age when the individual and the individual's partner have
the necessary gametes to establish a pregnancy , provided a pregnancy
loss shall not restart the six-month period.
Sec. 9. Subdivision (4) of subsection (b) of section 38a -509 of the
general statutes is repealed and the following is substituted in lieu
thereof (Effective January 1, 2027):
(4) Limit coverage for in -vitro fertilization, gamete intra -fallopian
transfer, zygote intra-fallopian transfer and low tubal ovum transfer to
those individuals who [have been unable to conceive or produce
conception or sustain a successful] meet the definition of infertility and
have been unable to establish a pregnancy or carry a pregnancy through
less expensive and medically viable infertility treatment or procedures
covered under such policy. Nothing in this subdivision shall be
construed to deny the co verage required by this section to any
individual who foregoes a particular infertility treatment or procedure
if the individual's physician determines that such treatment or
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procedure is likely to be unsuccessful; and
Sec. 10. Subsection (a) of section 38a -536 of the general statutes is
repealed and the following is substituted in lieu thereof (Effective January
1, 2027):
(a) Subject to the limitations set forth in subsection (b) of this section
and except as provided in subsection (c) of this section, each group
health insurance policy providing coverage of the type specified in
subdivisions (1), (2), (4), (11) and (12) of section 38a -469 delivered,
issued for delivery, amended, renewed or continued in this state on or
after January 1, 2018, shall provide coverage for the medically necessary
expenses for the diagnosis and treatment of infertility, including, but not
limited to, ovulation induction, intrauterine insemination, in -vitro
fertilization, uterine embryo lavage, embryo transfer, gamete intra -
fallopian transfer, zygote intra -fallopian transfer and low tubal ovum
transfer. For purposes of this section, "infertility" means [the condition
of an individual who is unable to conceive or produce conception or
sustain a successful pregnancy during a one -year period or such
treatment is medically necessary] (1) the inability to establish or carry a
pregnancy based on an individual's medical, sexual and reproductive
history, age, physical findings, diagnostic testing or any combination of
such factors, including, but not limited to, infertility arising from
disabilities or from medical treatments or conditions associated with a
disability, (2) the need for medical intervention, including, but not
limited to, the use of donor gametes, donor embryos or a gestational
surrogate, to establish a pregnancy either as a n individual or with a
partner, (3) an individual's inability to establish a pregnancy or carry a
pregnancy to live birth after twelve months of unprotected sexual
intercourse when the individual and the individual's partner have the
necessary gametes to establish a pregnancy, provided a pr egnancy loss
shall not restart the twelve -month period, and (4) an individual's
inability to establish a pregnancy or to carry a pregnancy to live birth
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after six months of unprotected sexual intercourse due to the
individual's age when the individual and the individual's partner have
the necessary gametes to establish a pregnancy , provided a pregnancy
loss shall not restart the six-month period.
Sec. 11. Subdivision (4) of subsection (b) of section 38a -536 of the
general statutes is repealed and the following is substituted in lieu
thereof (Effective January 1, 2027):
(4) Limit coverage for in -vitro fertilization, gamete intra -fallopian
transfer, zygote intra-fallopian transfer and low tubal ovum transfer to
those individuals who [have been unable to conceive or produce
conception or sustain a successful] meet the definition of infertility and
have been unable to establish a pregnancy or carry a pregnancy through
less expensive and medically viable infertility treatment or procedures
covered under such policy. Nothing in this subdivision shall be
construed to deny the co verage required by this section to any
individual who foregoes a particular infertility treatment or procedure
if the individual's physician determines that such treatment or
procedure is likely to be unsuccessful; and