Connecticut Public Act 10-24 went into effect January 1, 2011, and requires that in the event of a denial based on medical necessity and/or that the service is not a covered benefit under the policy, the insurer shall “(1) notify the insured that such insured may contact the Office of the Healthcare Advocate if the insured believes the insured has been given erroneous information, and (2) provide to such insured the contact information for said office.” The federal Patient Protection and Affordable Care Act (ACA), requires that as of July 1, 2011, all health plans or insurers, both fully-funded and self-funded, provide on all denial notices contact information for the state’s consumer assistance program (CAP) so consumers can get help with any questions or filing appeals. Connecticut’s CAP is the Office of the Healthcare Advocate (OHA).

Why are Public Act 10-24 and the Affordable Care Act (ACA) requirement so important?  Consumers win on appeal; getting them the assistance of a knowledgeable and successful consumer advocate like OHA to help with appeals can be critical. Statistics on successful appeals reported in the most recent Consumer Report Care on Health Insurance Carriers in Connecticut for internal appeals related to medical necessity show that those who appealed denials were successful between 31% and 75% of the time. Consumers in managed care indemnity plans were successful between 24% and 72% of the time where medical necessity was at issue.

External appeal statistics from 2008 through early 2010 are equally compelling. Among statistically valid samples, Anthem consumers were successful 39% for all medical necessity appeals and 48% of the time for the subset of behavioral health appeals.  For ConnectiCare, consumers’ external appeals were successful 34 percent overall and 35 percent of the time for behavioral health cases.  While the denials of care reported in the managed care report card do not include denials of coverage that don’t involve utilization review, such as denials for non-covered services and denials based on coding or billing errors, the reversal rates demonstrate a significant level of incorrect coverage decisions by managed care organizations.

Public Act 10-24 and the ACA notice requirements are important to increase the number consumer appeals, and correspondingly, their success rate. In the last two years too few consumers appealed denials from their insurance companies and held their insurance companies accountable.  Consumers in HMO plans appealed only 5 percent of the nearly 40,000 denials where medical necessity was at issue. Consumers in managed care indemnity plans appealed only 14 percent of denials where medical necessity was at issue.  The low percentage of consumers appealing denials suggests that many consumers feel that appealing denials is too burdensome, they have no chance at a reversal or they don’t know where to go for help.

By referring consumers directly to OHA, the legislature recognized the high quality consumer assistance that OHA provides to Connecticut healthcare consumers.

OHA is an independent state agency unrivaled in its success, and the only state agency dedicated solely to health insurance consumer advocacy, is unrivaled in its success. In 2010, OHA served approximately 2,200 consumers. Nearly one-quarter of those cases were personal referrals.  Ten percent of the cases referred to OHA came from legislators.  OHA’s success in advocating for reversals of medical necessity denials and denials of coverage in 2010 resulted in consumer savings of $5.66 million.  Ninety-six percent of consumers that received assistance at OHA said they would contact OHA again. The same percentage would refer someone to our office for assistance.

Connecticut healthcare consumers will have extra incentive to appeal denials now that they will know how to contact OHA for help with appeals.  A much higher rate of appeals of denials and continued advocacy to prevent wrongful denials of care up front will ensure that consumers receive the medical care they need, while holding insurers accountable. 

Vicki Veltri is currently the Acting State Healthcare Advocate.