CHAPTER 706b

OFFICE OF THE HEALTHCARE ADVOCATE

Table of Contents

Sec. 38a-1040. Definitions.

Sec. 38a-1041. Office of the Healthcare Advocate 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 advocate services.

Sec. 38a-1047. Conflicts of interest.

Sec. 38a-1048. Acceptance of gifts and grants. Separate account established.

Sec. 38a-1049. Advisory committee established. Annual evaluation.

Sec. 38a-1050. Report required by advocate. Contents.

Sec. 38a-1051. Commission on Health Equity. Membership. Duties. Report to Governor and General Assembly.

Secs. 38a-1052 to 38a-1079. Reserved


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 service corporation, 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; P.A. 15-118, S. 24.)

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; P.A. 15-118 made a technical change in Subdiv. (2).

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.

(g) Not later than January 1, 2015, 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.

(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.)

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.

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

Sec. 38a-1042. Appointment. (a) The Office of the Healthcare Advocate shall be under the direction of the Healthcare Advocate who shall be appointed by the Governor, with the approval of the General Assembly. The Healthcare Advocate 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 Healthcare Advocate shall not have served as a director or officer of a managed care organization within two years of appointment. In addition to the Healthcare Advocate, the Office of the Healthcare Advocate 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 the Healthcare Advocate 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 Healthcare Advocate not less than ninety days prior to the final day of the Healthcare Advocate's term in office. If a vacancy occurs in the position of Healthcare Advocate, the Governor shall notify the advisory committee immediately of the vacancy. The advisory committee shall meet to consider qualified candidates for the position of Healthcare Advocate 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 Healthcare Advocate'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 Healthcare Advocate. 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 Healthcare Advocate until the General Assembly meets and confirms the candidate as Healthcare Advocate. A candidate serving as acting Healthcare Advocate is entitled to compensation and has all the powers, duties and privileges of the Healthcare Advocate. A Healthcare Advocate shall serve a term of four years, not including any time served as acting Healthcare Advocate, and may be reappointed by the Governor or shall remain in the position until a successor is confirmed. Although an incumbent Healthcare Advocate 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 Healthcare Advocate, the most senior attorney in the Office of the Healthcare Advocate shall serve as the acting Healthcare Advocate until the vacancy is filled pursuant to subsection (a) or (b) of this section. The acting Healthcare Advocate has all the powers, duties and privileges of the Healthcare Advocate.

(P.A. 99-284, S. 3; P.A. 05-102, S. 9.)

History: P.A. 05-102 renamed the Office of Managed Care Ombudsman the Office of the Healthcare Advocate and made conforming changes.

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 the Healthcare Advocate access to records relating to such consumer.

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

(P.A. 99-284, S. 4; P.A. 05-102, S. 10.)

History: P.A. 05-102 renamed the Office of Managed Care Ombudsman the Office of the Healthcare Advocate.

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

(P.A. 99-284, S. 5; P.A. 05-102, S. 11.)

History: P.A. 05-102 renamed the Office of Managed Care Ombudsman the Office of the Healthcare Advocate.

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

(P.A. 99-284, S. 6; P.A. 05-102, S. 12.)

History: P.A. 05-102 renamed the Office of Managed Care Ombudsman the Office of the Healthcare Advocate.

Sec. 38a-1046. Employers required to post advocate services. Each employer that provides health insurance or health care benefits to employees shall obtain from the Healthcare Advocate and post, in a conspicuous location, a notice concerning the services that the Healthcare Advocate provides.

(P.A. 99-284, S. 7; P.A. 05-102, S. 13; P.A. 13-3, S. 77.)

History: P.A. 05-102 renamed the Managed Care Ombudsman the Healthcare Advocate; P.A. 13-3 deleted exclusion for self-insured employer and added “or health care” re benefits.

Sec. 38a-1047. Conflicts of interest. (a) No Healthcare Advocate or person employed by the Office of the Healthcare Advocate 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 Healthcare Advocate or person employed by the Office of the Healthcare Advocate 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 the Healthcare Advocate.

(P.A. 99-284, S. 8; P.A. 05-102, S. 14.)

History: P.A. 05-102 renamed the Office of the Managed Care Ombudsman the Office of the Healthcare Advocate and made conforming changes.

Sec. 38a-1048. Acceptance of gifts and grants. Separate account established. (a) The Office of the Healthcare Advocate 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 Healthcare Advocate 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 the Healthcare Advocate in the performance of its duties.

(P.A. 99-284, S. 9; P.A. 05-102, S. 15.)

History: P.A. 05-102 renamed the Office of Managed Care Ombudsman the Office of the Healthcare Advocate and made conforming changes.

Sec. 38a-1049. Advisory committee established. Annual evaluation. (a) There is established an advisory committee to the Office of the Healthcare Advocate which shall meet four times a year with the Healthcare Advocate and the staff of the Office of the Healthcare Advocate to review and assess the performance of the Office of the Healthcare Advocate. 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 the Healthcare Advocate 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 April first of each year commencing February 1, 2001.

(P.A. 99-284, S. 10; P.A. 05-15, S. 1; 05-102, S. 16; P.A. 10-32, S. 124.)

History: P.A. 05-15 amended Subsec. (b) to substitute “April first” for “February first”; P.A. 05-102 renamed the Office of Managed Care Ombudsman the Office of the Healthcare Advocate and made conforming changes; P.A. 10-32 made technical changes, effective May 10, 2010.

Sec. 38a-1050. Report required by advocate. Contents. The Healthcare Advocate shall submit, not later than March 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 Healthcare Advocate. The report shall include, but not be limited to, information regarding: (1) The subject matter, disposition and number of consumer complaints processed by the Healthcare Advocate; (2) common problems and concerns discerned by the Healthcare Advocate 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 the Healthcare Advocate.

(P.A. 99-284, S. 11; P.A. 05-15, S. 2; 05-102, S. 17.)

History: P.A. 05-15 substituted “March first” for “January first” re reports; P.A. 05-102 renamed the Office of Managed Care Ombudsman the Office of the Healthcare Advocate and made conforming changes.

Sec. 38a-1051. Commission on Health Equity. Membership. Duties. Report to Governor and General Assembly. Section 38a-1051 is repealed, effective July 1, 2016.

(P.A. 08-171, S. 1; P.A. 09-232, S. 9; Sept. Sp. Sess. P.A. 09-3, S. 38; P.A. 15-118, S. 59; May Sp. Sess. P.A. 16-3, S. 208.)

Secs. 38a-1052 to 38a-1079. Reserved for future use.