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OFFICE OF THE
HEALTHCARE
ADVOCATE



We're In Your Corner
A Message from your Healthcare Advocate
 

Welcome!
Did you know that historically, eight out of ten Americans search online for health information? It's probably even higher in the age of Covid-19 and now the Delta variant. This is a good thing, but medical information is most valuable when coupled with a strong healthcare policy that meets the needs of you and your family. Open enrollment begins November 1st. It's not too early to begin looking at your options. 

If you're a not for profit who is looking for extra eyeballs on your community events - OHA is providing an event listing that will hyperlink to your site. See our community events calendar on the OHA website for details. It's currently being developed, but for now, you'll be able to read the guidelines and see how they apply to your organization. 

And finally, here is another gentle reminder to make sure that all the people you know and love get vaccinated. Science shows us the vaccine works. It works better than a mask alone. As summer winds down, kids go back to school and college and we still struggle with the covid virus, please do your part. Vaccinate. It's free. It's effective. It could save a life, perhaps yours. 

Always In Your Corner, 


Ted Doolittle
Healthcare Advocate, State of Connecticut
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RECENT NEWS

Positive Health Insurance Changes

During this year's legislative session, the General Assembly passed Public Act 21-149, which requires health insurers to allow dependent children and young adults to remain on a parent or guardian’s vision and dental insurance through their 26th birthday.  This is a big change.

Previously, the Affordable Care Act allowed young adults to remain on their parents’ medical insurance through age 26, but the same was not always true for dental and vision coverage.  Under the ACA, pediatric care, which includes vision and dental services, is considered an essential health benefit and therefore subject to coverage through age 19.  Some individual and group health insurance plans can choose to insure children beyond that, but most reportedly don’t.

Beginning on January 1, 2022, fully insured health policies, such as individual and group plans on the state’s health insurance exchange, will be required to extend dependent eligibility for dental and vision coverage through age 26. Fully insured plans, which are state regulated, comprise about 30% of the policies in Connecticut. 


Not So Positive News

Once again, the healthcare insurance companies are seeking big rate hikes in the premiums that consumers and small businesses pay, whether they purchase the policy on or off the Affordable Care Act Exchange.  "We are studying the proposals," said Ted Doolittle, Connecticut State Healthcare Advocate. "These increases combined with earlier hikes in premiums pose a significant impact on consumers at a time when they can least afford it." 

The insurance industry is seeking a rate hike of 5.1% to 12.3% on individual health plans while demanding up to 15.8% increases from small groups. The industry fought a public option insurance plan earlier this year that was projected to provide lower cost plans. 

The state will hold one informational hearing August 31, just prior to Labor Day weekend where insurers will talk about why they're seeking the increases. The public can comment. The hearing will run from 9am to noon at 153 Market Street - 7th Floor in Hartford. The hearing will also be broadcast on the Insurance Department's YouTube channel. If you want to file written comments you can do so by writing cid.RateFIlings@ct.gov. Open enrollment begins November 1. 

Countdown Begins - Nosh and Know

Grab your lunch and spend a few minutes to get more acquainted with the fast changing world of healthcare insurance and how it affects you and your employees. Medical and Healthcare Insurance experts will be launching a Lunch and Learn effort to expand the public's knowledge of how OHA can help consumers and medical providers. The Zoom format webinars will only last 30 minutes once a month starting in September, with the topics covered changing with each session. There will be 15 minutes of presentation followed by 15 minutes for anyone to ask questions. A core mission of OHA is to constantly educate the public and those who work with and serve Connecticut residents. We'll make further announcements via social media and this newsletter. Follow us on Facebook.


OHA: We're in YOUR Corner

OHA Helps Medical Practices Too
Provider contacted OHA regarding an issue they were having with the insurance company regarding the correct processing of claims. The provider had submitted invoices for services rendered in an outpatient mental health program. The insurance carrier denied the claim citing "incorrect level of care" as the reason for the denial.   The company said the patient did not meet the level of care for a service they did not participate in. The provider had attempted for months to resolve the issue on their own with no success. OHA appealed the adverse determination by pointing out that the wrong criteria was applied to these claims. The carrier acknowledged the error and resubmitted the claims for processing. All claims were paid according to the terms of the benefit plan. The consumer had Medicaid as a secondary insurance, and therefore the member would have had no cost share, so cost avoidance saving was utilized as it saved Medicaid funds.


Collaborative Agencies Help Consumer
Client reached out to Office of the Healthcare Advocate after her daughter broke her arm and received emergency services while the family was on vacation in North Carolina. As a result, client incurred $10,000.00 in medical bills. Client is covered by by state Medicaid (HUSKY) rather than commercial insurance, which means many medical services received out of state would not be paid by her insurance, and the family would be financially responsible. Mother of the dependent child cited ongoing financial issues and struggles that were intensified due to the COVID-19 pandemic.

OHA called the North Carolina providers to educate providers on enrolling in CT Medicaid and tried to assist the client in getting claims paid by CT Medicaid. North Carolina providers initially did not have any interest enrolling in CT Medicaid and OHA outreach was unsuccessful. 

OHA pursued the assistance of fellow state agency, The Department of Social Services, specifically DSS Medical Operations. Negotiations with the out of state providers were ultimately successful, and the providers enrolled in CT Medicaid, which allowed for medical claims to be paid and processed by CT Medicaid. Efforts from OHA resulted in a consumer savings of $9,825.42. OHA notified the family by phone and email to share the good news/resolution.



Baby Consumer Gets Formula
Client contacted OHA due to a denial for his son’s formula. His son has acid reflux and the Pediatrician prescribed him infant specialized formula- Similac Alimentum for his sensitive stomach. The pharmacy insurance plan  denied the formula because it was a plan exclusion. OHA assisted the family with advising them to go to a  specialist- their doctor, to have the authorization sent to the medical insurance plan. The family took the OHA case worker’s advice and authorization was approved for 2021.OHA has had similar cases in which the formula is denied,  but is medically necessary. Many times the formula authorization is submitted to the pharmacy plan in error.  Specialized formulas if covered by the plan have to be submitted to the medical plan. Under Connecticut law specified health insurance policies are required to cover specialized formula on the same basis as outpatient prescription drugs if the formula is (1) medically necessary to treat a disease or condition and (2) administered under a physician's direction  (CGS §§ 38a-492c(c) and 38a-518c(c)). This statute applies to fully insured plans in the state of Connecticut.


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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. 

The OHA will help you during this crisis get you the assistance you need. 
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Our New Website

We invite you to visit our new website!
It can be found here: https://portal.ct.gov/oha
Notice the new address. It’s slightly different than the old one but no worries if you happen to forget, it will automatically redirect you to our new one. Read, enjoy, be informed and know your rights and responsibilities in the fast moving world of healthcare insurance. There are many helpful tips, links and great information you’ll find useful.
Our Mission
The mission of the Office of the Healthcare Advocate (OHA) is to assist consumers with healthcare issues through the establishment of effective outreach programs and the development of communications related to consumer rights and responsibilities as members of healthcare plans.  OHA focuses on assisting consumers in making informed decisions when selecting a health plan; assisting consumers to resolve problems with their health insurance plans and tracking trends of issues/problems, which may require administrative or legislative intervention, or advocacy with industry, the public, or other stakeholders
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Our mailing address is:
Office of the Healthcare Advocate
P.O. BOX 1543
Hartford CT 06144
Phone Number: 1-866-466-4446
Fax: 860-331-2499

Email: Healthcare.Advocate@ct.gov

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