EOB Confidentiality

New legislation passed during this year's legislative session will require health insurers in Connecticut to follow certain directives issued by consumers in order to protect the consumer’s privacy and personal health information.  Under current law, when a consumer receives health care services that are covered by their insurance policy, the insurer will issue an Explanation of Benefits (EOB), which typically identifies both the provider who rendered the services and the services that were provided.

If a consumer is enrolled as a dependent under another person’s policy, a copy of the EOB issued by the insurer is routinely sent to the subscriber, either in addition to or in lieu of the EOB that is sent to the dependent consumer.  In many circumstances, certain consumers (e.g., adult children) who may be enrolled as a dependent under a parent or another family member’s health plan, do not want details of their health care treatment exposed to other parties through an EOB.

Public Act 21-22 offers additional privacy protections for those dependents.  Under the new law, beginning January 1, 2023, insurers will be required to issue explanations of benefits (EOBs) in accordance with the instructions of an adult dependent (and certain minor dependents), which instructions may include: 1) issuing no EOBs; 2) issuing EOBs only to the insured and not to other individuals, such as the subscriber; and 3) issuing EOBs to a specific mailing address or email address or through other electronic means.


 

Expanding Insurance Coverage
A Top Priority

The new head of the federal agency that oversees health benefits for nearly 150 million Americans and $1 trillion in federal spending said in one of her first interviews that her top priorities will be broadening insurance coverage and ensuring health equity.

“We’ve seen through the pandemic what happens when people don’t have health insurance and how important it is,” said Chiquita Brooks-LaSure, who was confirmed by the Senate to lead the Centers for Medicare & Medicaid Services on May 25 and sworn in on May 27. “Our focus is going to be on making sure regulations and policies are going to be focused on improving coverage.”

It is an abrupt switch from the Trump administration, which steered the agency to spearhead efforts to repeal the Affordable Care Act and scale back Medicaid, the federal-state program for those with low incomes.

Brooks-LaSure, whose agency oversees the ACA marketplaces in addition to Medicare, Medicaid and the Children’s Health Insurance Program, said she is not surprised at the robust takeup of ACA insurance since President Joe Biden reopened enrollment in January. The administration announced last month that more than 1 million people had signed up already.

This is a reprint of a story first reported by NPR and reposted on the CT Mirror. Read the full account here.

OHA: We're in YOUR Corner

Following an emergency hospitalization, a consumer’s insurance denied coverage of the hospital stay as not medically necessary. Her insurance denied her inpatient submission based on her medical records from the hospital. The insurance said they couldn’t approve coverage for hospital admission because the testing from the hospital did not show she had a severe problem or that she needed to be admitted to the hospital. For this reason, her plan said her hospital stay was not medically necessary and denied it. OHA case manager filed a grievance for the denied hospital stay, and on reconsideration, the insurance plan determined that the hospital could not bill the consumer under the terms of their provider agreement. The consumer was not required to pay the hospital.
 
Client contacted OHA because she has ongoing migraines and her medication was suddenly dropped from insurance plan. They stated she did not meet the requirements of her plan. Client can only take this specific type of medication due to being allergic to many others and contacted OHA for help. OHA Case worker worked diligently, gathering all the necessary documents to work to submit an appeal. After appeal, a formulary coverage exception was granted. The appeal was successful resulting in approval of the necessary medications saving the consumer $7,241.76. Client thanked OHA for their services and appreciated the time and effort they put into trying to get the medications covered under their insurance plan.
 
Consumer reached out to OHA regarding an out-of-network mental health provider.  OHA requested an in-network exception for telehealth visits during COVID-19 pandemic.  The consumer was unable to find an in-network provider during this time.  The carrier made an exception request for 4 months for continuation of care until December 2020.  All claims were processed at the in-network rate with a zero dollar patient responsibility. OHA saved this consumer $650.

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OHA has saved consumers tens of millions of dollars since the agency was launched - and we've become a trusted resource and consumer advocate on all matters of healthcare insurance here in Connecticut and on developments in Washington, D.C. that can affect us. We share these changes and information  in many ways - social platforms like our page on Facebook and Twitter, press conferences and via this newsletter. If you know somebody who is not getting this newsletter on a regular basis - or is only getting it because it's shared with them - OHA invites one and all to join our exclusive email list. Sign up for the newsletter here.