Consumer Protection Programs,
Washington State Office of the Insurance Commissioner

These programs used their consumer assistance program grants to target their outreach and educational efforts to the state’s growing minority and senior populations, to create a guide to help consumers navigate the state’s health coverage appeals process, and to improve their data collection and case management software.

Program Structure and Services

Washington’s Office of the Insurance Commissioner (OIC) provides consumer assistance through its Consumer Protection Division call center. The Consumer Advocacy Program receives calls from the call center and is staffed by nine health, disability, and life insurance analysts. These analysts answer health insurance questions; educate consumers about their rights and responsibilities; help resolve insurance complaints; and work closely with the Office of the Insurance Commissioner’s legal department, which takes corrective action when insurers violate state or federal laws.

The Statewide Health Insurance Benefits Advisor (SHIBA) program also receives calls from the call center. SHIBA has a network of 400 volunteers and works with community-based organizations across the state. The SHIBA program began as a program that focused on educating seniors and helping them with Medicaid and Medicare issues. Now, both the Consumer Advocacy Program and SHIBA provide assistance to consumers with private insurance, as well as those who are enrolled in public programs, including Medicaid, Medicare, CHIP, the state’s Basic Health program, and the state’s high-risk pool.

To distinguish between the programs, the SHIBA program focuses on consumer outreach and in-person counseling, helping consumers understand their coverage options and enroll in coverage, and they conduct community-based education and training. The Consumer Advocacy Program focuses on resolving complex consumer complaints and problems, assisting with coverage appeals, and identifying systemic policy and enforcement issues through data collection and case analysis.

Between November 2010 and October 2011, health analysts with the Consumer Advocacy Program answered more than 19,000 consumer calls, and the call center referred approximately 20,000 calls to the SHIBA program for assistance.

The Office of the Insurance Commissioner raises core agency funding through a state assessment on insurers. This mechanism provides a sustainable source of funding for the agency, ensuring that the vital services it provides are not subject to funding reductions if the state cuts programs to fill budget shortfalls.

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

The Office of the Insurance Commissioner received a federal consumer assistance grant of $647,860 in October 2010 and an additional $100,594 in January 2011. The Consumer Protection Division used this funding to hire temporary staff and to fund permanent staff in several new project positions; expand its outreach and education efforts with a focus on minority populations and seniors; develop educational materials on health care appeals and on the Affordable Care Act; enhance its telephone, data collection, and case management technologies; and promote its services. The SHIBA and Consumer Advocacy Programs also provided subject matter expertise and additional staffing to support the new projects.

One of the new projects that the Consumer Protection Division developed was its Outreach Project. This project identified three target groups for outreach: the growing Latino and Chinese populations and the state’s senior population. From January through September 2011, an outreach coordinator that was funded by the program gave 60 presentations, some fully translated into Spanish or Chinese, at community organizations serving predominantly Latino communities in Southeastern Washington, Chinese communities in the Seattle metropolitan area, and seniors throughout the state. These presentations were also attended by social service providers, consumer advocates, health care providers, small business owners, and young adults. The presentations provided unbiased information about the new opportunities and consumer protections under the Affordable Care Act, educated consumers about common insurance issues, and informed consumers about the services provided by the Consumer Protection Division. To boost these efforts, the Outreach Project also translated all of its publications into Spanish and Chinese, including fact sheets, presentations, and guides to finding health coverage or low-cost care.

Consumers of all ages attended the outreach presentations on the Affordable Care Act. It was evident early on that many attendees were misinformed and knew little about the benefits under the new law. But as a result of attending these presentations, consumers learned about new coverage options that were available for themselves or for family members. In one case, a consumer mentioned that a relative was uninsured due to a pre-existing condition but intended to enroll in the Pre-existing Condition Insurance Program that was established under the health reform law. In another case, a young woman was pleased to learn that she was eligible for dependent coverage under her parents’ plan up to age 26.

Overall, the grant enabled consumers throughout the state to get answers to their questions about the new law and learn about changes under the law that could benefit them and their communities, such as the new health insurance exchanges and the Medicaid expansion. The presentations also gave state residents a chance to ask questions, and the program collected feedback from attendees through a short questionnaire. The questionnaire asked what topics were the most interesting and whether attendees had remaining questions, and it provided a space where they could share their personal experiences with the health care system. These presentations, together with spots on a Latino radio program and a local cable show, along with an AARP tele-townhall, reached nearly 15,000 people.

As part of its public education campaign, the Outreach Project also used free mass media and ethnic media outlets to advertise its services and inform the public about implementation milestones as key provisions of the Affordable Care Act went into effect. These provisions included coverage for young adults, free preventive care, assistance for seniors in the Part D coverage gap, and the establishment of the state’s Pre-Existing Condition Insurance Plan (PCIP).

Another project that was developed was the Appeals Guide project, which produced an online consumer guide to the state’s health care appeals process. The Appeals Guide explains consumer rights and provides step-by-step recommendations on how to successfully assemble, file, and follow up on insurance appeals. It also explains how the appeals process has been improved under the Affordable Care Act. This resource has received nationwide attention and is currently being used as a model for a consumer guide in Oregon. The Consumer Advocacy Program promoted the Appeals Guide through media outlets, blogs, and social media, which helped generate 12,951 page views between April and September 2011.

On December 1, 2011, the Office of the Insurance Commissioner began using the new data collection and case management technologies that were improved under the grant, which will enable insurance analysts, attorneys, and regulatory enforcement staff to view and work on a single case concurrently. A second phase of the IT project will move the SHIBA program’s current standalone data collection program to the agency’s newly enhanced platform, thus enabling consumers to receive seamless customer service when they are helped by either the Consumer Advocacy Program or SHIBA.

Consumer Story

The Consumer Advocacy Program frequently handles cases in which insurance companies have denied consumers coverage claiming that the treatment is “experimental,” “medically unnecessary,” or is related to a pre-existing condition. In one case, a consumer developed a medical problem a few months after he had enrolled in a new health plan. The consumer’s doctor recommended surgery, but his insurer refused to pay for it, saying that his condition was pre-existing and that they would pay for the surgery only after his pre-existing exclusion period had ended. With the help of an insurance analyst, the consumer filed an appeal and submitted medical documentation from his doctor showing that the condition was not pre-existing. Based on the additional evidence, the consumer won the appeal, and his insurance plan agreed to cover the surgery, which cost approximately $10,000. Insurance analysts who have worked on these types of cases note that they frequently see consumers win appeals when they can prove that it’s less expensive for the insurance company to treat the condition right away instead of waiting for the condition to become worse.

Sources

• Interview between Elaine Saly, Families USA, and Mary Childers, Consumer Advocacy Program Manager, Consumer Protection Division, Washington State Office of the Insurance Commissioner, November 2, 2011.
• Interview between Elaine Saly, Families USA, and Molly Nollette, Project Manager, Consumer Protection Division, Washington State Office of the Insurance Commissioner, November 3, 2011.
• Interview between Elaine Saly, Families USA, and Chewon Lee, Strategic Partnership Development Specialist, Consumer Protection Division, Washington State Office of the Insurance Commissioner, November 4, 2011.
• Mike Kreidler, Insurance Commissioner, Washington State Office of the Insurance Commissioner, State of Washington Insurance Commissioner’s Annual Report 2010 (Olympia, WA: Washington State Office of the Insurance Commissioner, June 2011), available online at http://www.insurance.wa.gov/publications/annual_reports/2010reportappendix/AnnualRpt2010.pdf.
• Consumer publications developed by the Consumer Protection Division of the Washington State Office of the Insurance Commissioner are available on the program’s website at http://www.insurance.wa.gov/publications/index.shtml#health. The division’s consumer guide to the health coverage appeals process, How to Appeal a Health Care Insurance Decision: A Guide for Consumers in Washington State, is available online at http://www.insurance.wa.gov/consumers/health/appeal/Table-of-Contents.shtml.
• Consumer Protection Division, Washington State Office of the Insurance Commissioner, Analytics Report (Olympia, WA: Washington State Office of the Insurance Commissioner, September 26, 2011).

PDF of this profile is available.