Consumer Services Division,
Georgia Department of Insurance

The program ensures that new coverage programs work for Georgia residents.

Program Structure and Services

The Consumer Services Division in the Georgia Department of Insurance helps policyholders work through insurance issues and file formal complaints with the Department of Insurance. The division also investigates complaints to determine if insurers are in compliance with state law. Its Managed Care Unit focuses on resolving complex claims problems between health care providers and managed care insurers, and it conducts provider education about claims filing and payment practices for managed care organizations.

Health insurance inquires make up more than half of the calls taken by the division, and staff have noted an increase in calls from consumers in the past few years. In 2010, the division received more than 7,000 calls from health care consumers. Many of the callers had lost job-based coverage due to business cutbacks or layoffs, or they were searching for coverage after being denied private insurance based on a pre-existing condition. Program counselors help consumers who are uninsured sign up for COBRA insurance (when they are eligible and able to afford COBRA premiums), find low-cost or free care, or enroll in the federal Pre-Existing Condition Insurance Program (PCIP). The division has been a key partner to the state in making sure that Georgia residents with serious pre-existing health conditions are able to get coverage through the PCIP, identifying enrollment issues and helping clarify eligibility criteria as the program launched (see the Consumer Stories for more details). In 2010, when a number of plans stopped offering child-only policies, the division was active in helping children with pre-existing conditions enroll in the PCIP.

Program Education and Outreach

The division engages with consumers and health care stakeholders throughout the state by sending email updates to more than 10,000 subscribers and participating in regionally based advisory committees. The program advertises its services by participating in large public events, posting its toll-free number on government agency websites, generating press coverage by sending press releases to community newspapers, and developing relationships with the constituent services staff for state legislators.

How Did Consumer Assistance Grant Funding Help the Consumer Services Division?

The Consumer Services Division received $822,156 in consumer assistance grant funding in 2010, enabling it to hire additional staff and to expand its services. These services included providing assistance with filing internal appeals, counseling in Spanish, and specialized help for consumers in self-funded plans. The division is also upgrading its telephone system, and the new system will enable staff to see which counselors are occupied so they can direct calls efficiently to minimize hold times and busy signals. Staff will also be able to collect, track, and report data about the complaints filed through the new phone system while protecting callers’ personal information.

Consumer Stories

Shortly after the PCIP was established, the division received calls from consumers who were told that they were not eligible for PCIP coverage because, when asked whether they currently had any type of coverage, they said that they did. However, what these consumers actually had was discounts on medical services though pharmacy programs—not health coverage. Counselors in the division contacted the Center for Consumer Information and Insurance Oversight (CCIIO), the federal agency that oversees PCIPs, and it was able to set up a call with both division staff and PCIP program administrators to clarify program policy. It turned out that the consumers were in fact eligible to receive coverage through the PCIP, and these consumers were subsequently enrolled.

The alert from consumer services staff prompted CCIIO to write new scripts for PCIP eligibility call centers that require staff to ask applicants more detailed questions to identify whether consumers have creditable coverage (these scripts apply to states that have federal PCIPs). This helps ensure that programs have all of the information needed to issue coverage determinations.

Source

• Interview between Cheryl Fish-Parcham and Elaine Saly, Families USA, and Consumer Services Division program staff, July 1, 2011.

PDF of this profile is available.