Insurance Commissioner: Know How to Use Your Health Insurance Plan

Connecticut Insurance Commissioner Andrew N. Mais reminds consumers who have chosen health insurance plans during the recent open enrollment to take the time to understand their plan and know how to use it.

More than 150,000 people enrolled in Affordable Care Act (ACA) plans through Access Health CT, the state’s health insurance marketplace during open enrollment, which ended Jan. 15.

“The robust benefits in Connecticut’s fully insured ACA plans are there to use in times of emergency and illness but also to help maintain health and well-being. It’s also just as important that consumers know their rights if a claim is denied,” Commissioner Mais said. “The Connecticut Insurance Department can help address questions or concerns you may have.”

Understand What Is Covered

The ACA-compliant plans provide essential benefits that include:

• Outpatient and emergency services;
• Lab work;
• Prescription drugs;
• Maternity and newborn care;
• Physical therapy; and
• Mental health and substance abuse disorder treatment.

ACA plans also cover preventive and wellness services, such as screenings and vaccinations, often at no out-of-pocket cost to the policyholder.

Know Your Rights if A Claim is Denied

You have the right to appeal any type of claims denial directly with your insurer.

If you have exhausted your appeals with the insurance company, you may qualify for an External Review, in which an independent third-party organization reviews the decision. Denials that qualify for an External Review include treatment that is:

• Considered not medically necessary
• No longer needed in the health care setting
• Considered experimental or investigational
• Out-of-network provider not needed due to adequate providers in network

You can apply for an External Review through the Insurance Department’s Consumer Affairs Division.

For more information, visit the Insurance Department’s Understanding Health Insurance or contact us at insurance@ct.gov or by calling the Consumer Helpline at 860-297-3900.