Connecticut Office of the Healthcare Advocate
This stand-alone state agency works with other agencies and groups to address consumer problems at both the individual and system levels.
Program Structure and Services
The Office of the Healthcare Advocate (OHA) is a stand-alone agency that was established by the Connecticut legislature in 1999. The office educates health care consumers; works with insurance companies on behalf of consumers; helps consumers file appeals and present relevant evidence when they disagree with claim denials; facilitates coordination among government agencies that serve health care consumers; and engages in policy advocacy to strengthen consumer rights and enforce insurance industry oversight. The program receives some funding through a state tax on insurers, and it relies on grants for the remaining funding.
OHA works in partnership with the Connecticut Attorney General's Office to bring attention to difficult consumer cases, particularly when these cases demonstrate an underlying problem with health coverage. OHA also regularly testifies in legislative hearings on behalf of Connecticut health care consumers. In 2009, the office worked on landmark legislation to prevent “post-claims underwriting” before the nation addressed the similar problem of unfair insurance cancellations through the Affordable Care Act.
In 2010, Connecticut passed legislation that requires insurers to list OHA’s contact information on health plan denial and adverse coverage letters, which has resulted in an increased number of requests for assistance. OHA pushed the state to adopt an additional requirement that all employers offering health coverage must display posters providing information about OHA’s services. This requirement may soon extend to self-insured employers as well.
OHA has also been successful in advocating for improvements in Connecticut’s premium rate review process, and the state is making strides in this area with the help of a new federal grant. In 2010, the Office of the Healthcare Advocate was able to prevent Anthem Blue Cross and Blue Shield from raising premiums by 20 percent on all individual policies. It did this by providing an actuarial analysis that showed that premiums were already sufficient. The office also demanded transparency and an opportunity for consumers and advocates to have input in the state’s rate review process through public hearings.
The Affordable Care Act put in place new standards for premium rate review, and in 2010, states received federal grants to improve their rate review programs. For Connecticut, this funding enabled OHA to conduct a secondary review of Anthem’s premium increase proposal, which gave the Department of Insurance grounds on which to deny the insurer’s unreasonable proposal.
How Did Consumer Assistance Grant Funding Help the Office of the Health Care Advocate?
In November 2010, OHA received $396,400 in federal consumer assistance grant funding. One of the most important uses of the grant was hiring new staff, including an outreach coordinator, a licensed clinical social worker with a background in mental health issues, and a registered nurse consultant. Before it received this grant, the program badly needed additional funding so that it could serve the higher volume of consumers requesting assistance through the OHA helpline. In 2010, OHA worked on more than 3,300 cases—30 percent more than the previous year—and the program’s three full-time case managers were at capacity. OHA estimates that, in calendar year 2011, it will work on 6,000 cases.
Since many consumers contact OHA for help with appealing denials of mental health claims, OHA used its grant to enhance its assistance and referral relationships in this area. OHA developed relationships with other Connecticut agencies, such as the Department of Social Services, the Office of the Child Advocate, the Department of Children and Families, and the Department of Developmental Services, as well as advocacy organizations that have programs for people with a range of chronic and mental illnesses. These relationships have helped coordinate advocacy and services for people with specific health care needs and facilitated referrals among programs.
Recently, OHA learned that an insurer appeared to have been using criteria that violated the states’ mental health parity law to deny access to care, and it notified the Connecticut Insurance Department about the issue. This ultimately resulted in the state taking action against the insurer. OHA is now seeking systemic review of all cases in which insurers have used illegal criteria to deny access to medically necessary mental health and substance use treatment.
Public Education and Outreach
The federal grant also allowed OHA to better publicize its services. It hired a new outreach coordinator, who travels throughout the state to hold public education forums. In 2011, the program conducted more than 100 outreach events. In addition to doing outreach and advertising (including a television ad), the program publishes a newsletter with updates on legislative and industry activities, and it has developed educational brochures and web pages for consumers, providers, and employers that provide information about new rights, procedures, and laws, The program is also using ads online and in newspapers and banners on the backs of public buses. OHA plans to partner with the Connecticut Commission on Health Equity to expand its outreach efforts even more.
This outreach has contributed to increased case volume, but the additional staff hires have enabled the program to meet this need and continue the program’s high rate of success. In fiscal year 2011, OHA saved consumers $11 million—nearly twice its previous average of $6 million a year. Savings for calendar year 2011 are projected to exceed $12 million.
Consumer Story
The Office of the Healthcare Advocate assists consumers with choosing the right health plan by helping them understand the coverage that is provided in public and private insurance plans. It can be very difficult for consumers to evaluate the costs and benefits of an insurance plan, and many consumers are surprised to find that they have higher out-of-pocket costs than they expected or have coverage exclusions that they didn’t know about. In one such case, OHA helped a Medicare beneficiary who had enrolled in a Medicare Advantage plan that did not meet her needs. She had enrolled in the plan after reading through the plan’s advertising materials, as well as meeting with a representative to discuss what the copayments and co-insurance amounts would be for her anticipated treatments. The consumer chose a plan with a higher premium because she was assured she would have virtually no out-of-pocket expenses. However, when her claims were processed for the first two months of her coverage, she found that her copayments and co-insurance added up to well over $1,000. She contacted OHA, and OHA got in touch with the plan and negotiated with them so that the consumer could switch to a more appropriate plan for her medical and financial needs. OHA also persuaded the plan to refund the out-of-pocket expenses that the consumer had incurred.
Sources
- Interviews between Elaine Saly and Cheryl Fish-Parcham, Families USA, and Victoria Veltri, Connecticut State Health Care Advocate, and Laura Morris, Outreach Coordinator/Data Analyst for the Office of the Healthcare Advocate, June 18, 2011.
- Office of the Healthcare Advocate, State of Connecticut, State of the Office of the Healthcare Advocate: 2009 Annual Report (Hartford: Office of the Healthcare Advocate), available online at http://www.ct.gov/oha/lib/oha/documents/2009_office_of_the_healthcare_advocate_annual_report.pdf.
- Office of the Healthcare Advocate, State of Connecticut, Annual Report: Two Thousand Ten (Hartford: Office of the Health Care Advocate), available online at http://www.ct.gov/oha/lib/oha/documents/complete_annual_report_2010.pdf.
- Office of the Healthcare Advocate, State of Connecticut, Report to the Governor on Fiscal Year 2011 Activities (Hartford: Office of the Healthcare Advocate, August 2011), available online at http://www.ct.gov/oha/lib/oha/documents/fiscal_year_11_report_for_digest_with_2010_annual_report.pdf.
- Office of the Healthcare Advocate publications and resources for consumers, providers, and employers are available online at http://www.ct.gov/oha/cwp/view.asp?a=2258&q=300588.
PDF of this profile is available.
