CHAPTER 706b
OFFICE OF MANAGED CARE OMBUDSMAN

Table of Contents

Sec. 38a-1040. Definitions.
Sec. 38a-1041. Office of Managed Care Ombudsman established. Duties.
Sec. 38a-1042. Appointment.
Sec. 38a-1043. Access to information.
Sec. 38a-1044. State agency information and assistance.
Sec. 38a-1045. Confidentiality of consumer identity.
Sec. 38a-1046. Employers required to post ombudsman services.
Sec. 38a-1047. Conflicts of interest.
Sec. 38a-1048. Acceptance of gifts and grants. Separate account established.
Sec. 38a-1049. Advisory committee established. Report required by committee.
Sec. 38a-1050. Report required by ombudsman. Contents.

      Sec. 38a-1040. Definitions. As used in sections 38a-1040 to 38a-1050, inclusive:

      (1) "Consumer" means an individual who receives or is attempting to receive services from a managed care organization and is a resident of this state.

      (2) "Managed care organization" means an insurer, health care center, hospital or medical service corporation or other organization delivering, issuing for delivery, renewing or amending any individual or group health managed care plan in this state.

      (3) "Managed care plan" means a product offered by a managed care organization that provides for the financing or delivery of health care services to persons enrolled in the plan through: (A) Arrangements with selected providers to furnish health care services; (B) explicit standards for the selection of participating providers; (C) financial incentives for enrollees to use the participating providers and procedures provided for by the plan; or (D) arrangements that share risks with providers, provided the organization offering a plan described under subparagraph (A), (B), (C) or (D) of this subdivision is licensed by the Insurance Department pursuant to chapter 698, 698a or 700 and that the plan includes utilization review pursuant to sections 38a-226 to 38a-226d, inclusive.

      (P.A. 99-284, S. 1.)

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      Sec. 38a-1041. Office of Managed Care Ombudsman established. Duties. (a) There is established an Office of Managed Care Ombudsman which shall be within the Insurance Department for administrative purposes only.

      (b) The Office of Managed Care Ombudsman 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 section 38a-478n;

      (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 Managed Care Ombudsman provides;

      (10) Establish a toll-free number, or any other free calling option, to allow customer access to the services provided by the Managed Care Ombudsman;

      (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 Managed Care Ombudsman shall make a referral to the Insurance Commissioner if the Managed Care Ombudsman finds that a preferred provider network may have engaged in a pattern or practice that may be in violation of sections 38a-226 to 38a-226d, inclusive, 38a-479aa to 38a-479gg, inclusive, or 38a-815 to 38a-819, inclusive.

      (d) The Managed Care Ombudsman 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.

      (P.A. 99-284, S. 2; P.A. 03-169, S. 8.)

      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.

      See Sec. 4-38f for definition of "administrative purposes only".

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      Sec. 38a-1042. Appointment. (a) The Office of Managed Care Ombudsman shall be under the direction of the Managed Care Ombudsman who shall be appointed by the Governor, with the approval of the General Assembly. The Managed Care Ombudsman shall be an elector of the state with expertise and experience in the fields of health care, health insurance and advocacy for the rights of consumers, provided the ombudsman shall not have served as a director or officer of a managed care organization within two years of appointment. In addition to the Managed Care Ombudsman, the Office of Managed Care Ombudsman shall consist of a staff of not more than three persons, which staff may be increased as the requirements and resources of the office permit.

      (b) The Governor shall make the initial appointment of Managed Care Ombudsman from a list of candidates prepared and submitted, not later than June 1, 2000, to the Governor by the advisory committee established pursuant to section 38a-1049. The Governor shall notify the advisory committee of the pending expiration of the term of an incumbent ombudsman not less than ninety days prior to the final day of the ombudsman's term in office. If a vacancy occurs in the position of ombudsman, the Governor shall notify the advisory committee immediately of the vacancy. The advisory committee shall meet to consider qualified candidates for the position of ombudsman and shall submit a list of not more than five candidates to the Governor ranked in order of preference, not more than sixty days after receiving notice from the Governor of the pending expiration of the ombudsman's term or the occurrence of a vacancy. The Governor shall designate, not more than sixty days after receipt of the list of candidates from the advisory committee, one candidate from the list for the position of ombudsman. If, after the list is submitted to the Governor by the advisory committee, any candidate withdraws from consideration, the Governor shall designate a candidate from those remaining on the list. If the Governor fails to designate a candidate within sixty days of receipt of the list from the advisory committee, the advisory committee shall refer the candidate with the highest ranking on the list to the General Assembly for confirmation. If the General Assembly is not in session at the time of the Governor's or advisory committee's designation of a candidate, the candidate shall serve as the acting ombudsman until the General Assembly meets and confirms the candidate as ombudsman. A candidate serving as acting ombudsman is entitled to compensation and has all the powers, duties and privileges of the ombudsman. An ombudsman shall serve a term of four years, not including any time served as acting ombudsman, and may be reappointed by the Governor or shall remain in the position until a successor is confirmed. Although an incumbent ombudsman may be reappointed, the Governor shall also consider additional candidates from a list submitted by the advisory committee as provided in this section.

      (c) Upon a vacancy in the position of the ombudsman, the most senior attorney in the Office of Managed Care Ombudsman shall serve as the acting ombudsman until the vacancy is filled pursuant to subsection (a) or (b) of this section. The acting ombudsman has all the powers, duties and privileges of the ombudsman.

      (P.A. 99-284, S. 3.)

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      Sec. 38a-1043. Access to information. (a) Each managed care organization shall, when presented with the written consent of the consumer or the consumer's guardian or legal representative, provide to the Office of Managed Care Ombudsman access to records relating to such consumer.

      (b) Any records provided pursuant to this section to the Office of Managed Care Ombudsman shall be exempt from disclosure under the Freedom of Information Act, as defined in section 1-200.

      (P.A. 99-284, S. 4.)

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      Sec. 38a-1044. State agency information and assistance. All state agencies shall comply with reasonable requests of the Office of Managed Care Ombudsman for information and assistance.

      (P.A. 99-284, S. 5.)

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      Sec. 38a-1045. Confidentiality of consumer identity. In the absence of the written consent of a consumer utilizing the services of the Office of Managed Care Ombudsman or such consumer's guardian or legal representative or of a court order, the Office of Managed Care Ombudsman, its employees and agents, shall not disclose the identity of the consumer.

      (P.A. 99-284, S. 6.)

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      Sec. 38a-1046. Employers required to post ombudsman services. Each employer, other than a self-insured employer, that provides health insurance benefits to employees shall obtain from the Managed Care Ombudsman and post, in a conspicuous location, a notice concerning the services that the Managed Care Ombudsman provides.

      (P.A. 99-284, S. 7.)

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      Sec. 38a-1047. Conflicts of interest. (a) No ombudsman or person employed by the Office of Managed Care Ombudsman may:

      (1) Have a direct involvement in the licensing, certification or accreditation of a managed care organization;

      (2) Have a direct ownership or investment interest in a managed care organization;

      (3) Be employed by or participate in the management of a managed care organization; or

      (4) Receive or have the right to receive, directly or indirectly, remuneration under a compensation arrangement with a managed care organization.

      (b) No ombudsman or person employed by the Office of Managed Care Ombudsman may knowingly accept employment with a managed care organization for a period of one year following termination of that person's services with the Office of Managed Care Ombudsman.

      (P.A. 99-284, S. 8.)

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      Sec. 38a-1048. Acceptance of gifts and grants. Separate account established. (a) The Office of Managed Care Ombudsman may apply for and accept grants, gifts and bequests of funds from other states, federal and interstate agencies and independent authorities and private firms, individuals and foundations, for the purpose of carrying out its responsibilities.

      (b) There is established within the General Fund a managed care ombudsman account that shall be a separate nonlapsing account. Any funds received under this section shall, upon deposit in the General Fund, be credited to said account and may be used by the Office of Managed Care Ombudsman in the performance of its duties.

      (P.A. 99-284, S. 9.)

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      Sec. 38a-1049. Advisory committee established. Report required by committee. (a) There is established an advisory committee to the Office of Managed Care Ombudsman which shall meet four times a year with the Managed Care Ombudsman and the staff of the Office of Managed Care Ombudsman to review and assess the performance of the Office of Managed Care Ombudsman. The advisory committee shall consist of six members appointed one each by the president pro tempore of the Senate, the speaker of the House of Representatives, the majority leader of the Senate, the majority leader of the House of Representatives, the minority leader of the Senate and the minority leader of the House of Representatives. Each member of the advisory committee shall serve a term of five years and may be reappointed at the conclusion of that term. All initial appointments to the advisory committee shall be made not later than March 1, 2000.

      (b) The advisory committee shall make an annual evaluation of the effectiveness of the Office of Managed Care Ombudsman and shall submit the evaluation to the Governor and the joint standing committees of the General Assembly having cognizance of matters relating to public health and insurance not later than February first of each year commencing February 1, 2001.

      (P.A. 99-284, S. 10.)

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      Sec. 38a-1050. Report required by ombudsman. Contents. The Managed Care Ombudsman shall submit, not later than January first of each year, a report to the Governor and the joint standing committees of the General Assembly having cognizance of matters relating to public health and insurance concerning the activities of the ombudsman. The report shall include, but not be limited to, information regarding: (1) The subject matter, disposition and number of consumer complaints processed by the ombudsman; (2) common problems and concerns discerned by the ombudsman from the consumer complaints and other relevant sources; (3) the need, if any, for administrative, legislative or executive remedies to assist consumers; and (4) the fiscal accounts of the Office of Managed Care Ombudsman.

      (P.A. 99-284, S. 11.)

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