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, as defined in section 38a-591a.
(P.A. 99-284, S. 1; P.A. 11-58, S. 86.)
History: P.A. 11-58 replaced reference to Secs. 38a-226 to 38a-226d with "as defined in section 38a-591a" in Subdiv. (3), effective July 1, 2011.
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Sec. 38a-1041. Office of the Healthcare Advocate established. Duties. (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) On or before October 1, 2005, 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) On or before October 1, 2008, the Office of the Healthcare Advocate shall, within available appropriations, establish and maintain a healthcare consumer information web site on the Internet for use by the public in obtaining healthcare 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-478l.
(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.)
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.
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