§ 38a-1041 — Office of the Healthcare Advocate established. Duties.

Connecticut § 38a-1041

• Jurisdiction: Connecticut
• Title 38a: Insurance
• Ch. 706b: Office of the Healthcare Advocate and Office of the Behavioral Health Advocate

Text

(a) There is established an Office of the Healthcare Advocate which shall be within the Insurance Department for administrative purposes only. (b) The Office of the Healthcare Advocate may: (1) Assist health insurance consumers with managed care plan selection by providing information, referral and assistance to individuals about means of obtaining health insurance coverage and services; (2) Assist health insurance consumers to understand their rights and responsibilities under managed care plans; (3) Provide information to the public, agencies, legislators and others regarding problems and concerns of health insurance consumers and make recommendations for resolving those problems and concerns; (4) Assist consumers with the filing of complaints and appeals, including filing appeals with a managed care organization's internal appeal or grievance process and the external appeal process established under sections 38a-591d to 38a-591g , inclusive; (5) Analyze and monitor the development and implementation of federal, state and local laws, regulations and policies relating to health insurance consumers and recommend changes it deems necessary; (6) Facilitate public comment on laws, regulations and policies, including policies and actions of health insurers; (7) Ensure that health insurance consumers have timely access to the services provided by the office; (8) Review the health insurance records of a consumer who has provided written consent for such review; (9) Create and make available to employers a notice, suitable for posting in the workplace, concerning the services that the Healthcare Advocate provides; (10) Establish a toll-free number, or any other free calling option, to allow customer access to the services provided by the Healthcare Advocate; (11) Pursue administrative remedies on behalf of and with the consent of any health insurance consumers; (12) Adopt regulations, pursuant to chapter 54, to carry out the provisions of sections 38a-1040 to 38a-1050 , inclusive; and (13) Take any other actions necessary to fulfill the purposes of sections 38a-1040 to 38a-1050 , inclusive. (c) The Office of the Healthcare Advocate shall make a referral to the Insurance Commissioner if the Healthcare Advocate finds that a preferred provider network may have engaged in a pattern or practice that may be in violation of sections 38a-479aa to 38a-479gg , inclusive, or 38a-815 to 38a-819 , inclusive. (d) The Healthcare Advocate and the Insurance Commissioner shall jointly compile a list of complaints received against managed care organizations and preferred provider networks and the commissioner shall maintain the list, except the names of complainants shall not be disclosed if such disclosure would violate the provisions of section 4-61dd or 38a-1045 . (e) The Managed Care Ombudsman shall establish a process to provide ongoing communication among mental health care providers, patients, state-wide and regional business organizations, managed care companies and other health insurers to assure: (1) Best practices in mental health treatment and recovery; (2) compliance with the provisions of sections 38a-476a , 38a-476b , 38a-488a and 38a-489 ; and (3) the relative costs and benefits of providing effective mental health care coverage to employees and their families. On or before January 1, 2006, and annually thereafter, the Healthcare Advocate shall report, in accordance with the provisions of section 11-4a , on the implementation of this subsection to the joint standing committees of the General Assembly having cognizance of matters relating to public health and insurance. (f) The Office of the Healthcare Advocate shall, within available appropriations, establish and maintain a health care consumer information Internet web site for use by the public in obtaining health care information, including, but not limited to: (1) The availability of wellness programs in various regions of Connecticut, such as disease prevention and health promotion programs; (2) quality and experience data from hospitals licensed in this state; and (3) a link to the consumer report card developed and distributed by the Insurance Commissioner pursuant to section 38a-478 l . (g) The Office of the Healthcare Advocate shall establish an information and referral service to help residents and providers receive behavioral health care information, timely referrals and access to behavioral health care providers. In developing and implementing such service, the Healthcare Advocate, or the Healthcare Advocate's designee, shall: (1) Collaborate with stakeholders, including, but not limited to, (A) state agencies, (B) the Behavioral Health Partnership established pursuant to section 17a-22h , (C) community collaboratives, (D) the United Way's 2-1-1 Infoline program, and (E) providers; (2) identify any basis that prevents residents from obtaining adequate and timely behavioral health care services, including, but not limited to, (A) gaps in private behavioral health care services and coverage, and (B) barriers to access to care; (3) coordinate a public awareness and educational campaign directing residents to the information and referral service; and (4) develop data reporting mechanisms to determine the effectiveness of the service, including, but not limited to, tracking (A) the number of referrals to providers by type and location of providers, (B) waiting time for services, and (C) the number of providers who accept or reject requests for service based on type of health care coverage. Not later than February 1, 2016, and annually thereafter, the Office of the Healthcare Advocate shall submit a report, in accordance with the provisions of section 11-4a , to the joint standing committees of the General Assembly having cognizance of matters relating to children, human services, public health and insurance. The report shall identify gaps in services and the resources needed to improve behavioral health care options for residents. (h) Not later than October 1, 2022, the Healthcare Advocate shall designate an employee of the Office of the Healthcare Advocate to be responsible for: (1) Performing the office's duties to minors; and (2) coordinating state-wide efforts to ensure that minors have coverage, and access to services, for behavioral health conditions, mental health conditions and substance use disorders. See Sec. 4-38f for definition of “administrative purposes only”.

Legislative History

(P.A. 99-284, S. 2; P.A. 03-169, S. 8; P.A. 05-102, S. 8; 05-280, S. 89; P.A. 07-185, S. 22; P.A. 11-58, S. 87; 11-215, S. 11; P.A. 14-115, S. 1; P.A. 22-47, S. 11; P.A. 24-24, S. 30.) History: P.A. 03-169 added Subsecs. (c) and (d) re referrals to commissioner re preferred provider networks and re list of complaints against managed care organizations and preferred provider networks, respectively; P.A. 05-102 renamed the Office of Managed Care Ombudsman the Office of the Healthcare Advocate, and renamed the Managed Care Ombudsman the Healthcare Advocate; P.A. 05-280 added new Subsec. (e) re establishment by Managed Care Ombudsman of process for communication among mental health care providers and others, effective July 13, 2005 (Revisor's note: Pursuant to P.A. 05-102 a reference to “Managed Care Ombudsman” in provision re reports was changed editorially by the Revisors to “Healthcare Advocate”); P.A. 07-185 added Subsec. (f) requiring Office of the Healthcare Advocate to establish and maintain, within available appropriations, a healthcare consumer information website on the Internet; P.A. 11-58 amended Subsec. (b)(4) by replacing reference to Sec. 38a-478n with “sections 38a-591d to 38a-591g, inclusive” and amended Subsec. (c) by deleting reference to Secs. 38a-226 to 38a-226d, effective July 1, 2011; P.A. 11-215 amended Subsec. (e) by deleting requirement that Managed Care Ombudsman consult with Community Mental Health Strategy Board; P.A. 14-115 added Subsec. (g) re establishment of behavioral health care information and referral service, effective July 1, 2014; P.A. 22-47 amended Subsecs. (e) to (g) by making technical changes, and added Subsec. (h) re designation of employee responsible for mental health coverage considerations for minors, effective July 1, 2022; P.A. 24-24 made technical changes in Subsec. (f).