Connecticut State Office of the Healthcare Advocate

NOTICE: The Office of the Healthcare Advocate is currently closed to public visitors as a protective measure for the safety of customers and staff. We will continue to provide services by email and telephone. The Office of the Healthcare Advocate may be contacted by utilizing our on-line services on our website, by calling our main number at 1-866-466-4446 or by emailing us at healthcare.advocate@ct.gov

Rules and Regulations

Governor Lamont's Executive Orders - a summary of Governor Lamont's Executive Orders related to healthcare and healthcare insurance during the COVID-19 pandemic.

COMMERCIAL HEALTH INSURANCE

Commercial health insurance can take various forms, including fully-insured individual and group health insurance policies, self-insured or level-funded employer sponsored health plans, short-term limited duration health plans, association health plans, among others.  The rules and regulations that apply to the various forms of commercial health plans can differ depending on the nature and structure of the plan, where it is issued, who offers it, and other factors. The following links provide more information about some of the most commonly referenced rules and regulations pertaining to commercial health insurance plans.

CT General Statutes Title 38a, Chapter 700c - Connecticut state laws regarding fully-insured individual and group health insurance policies and other forms of health insurance subject to state regulation

Connecticut General Statutes Sec. 38a-477aa - Connecticut's Surprise Billing Statute

Connecticut General Statutes Sec. 38a-477bb - Connecticut statute regarding cost sharing for facility fees

Code of Federal Regulations Title 45, Subchapter B - Rules promulgated by the U.S. Department of Health & Human Services (HHS) setting forth requirements for individual and group health insurance plans, and also prescribing rules applicable to the establishment and operation of the federal and state-based health insurance exchanges 

Health Care (HC) Bulletins - Notices issued by the Connecticut Insurance Department to provide guidance and clarification regarding the application of insurance laws and regulations.

United States Preventive Services Task Force (USPSTF) Recommendations - Recommended preventive services published by the United States Preventive Services Task Force (USPSTF).  Generally, recommended services with an A or B rating must be covered by your health insurance without any cost sharing.

Women's Preventive Services Guidelines - Additional recommended preventive services related to women's health published by the Health Resources & Services Administration (HRSA).  Generally, preventive services recommended by the HRSA must be covered by your health insurance without any cost sharing.

Employee Retirement Income Security Act (ERISA)

The Employee Retirement Income Security Act of 1974 (ERISA), which is codified under Title 29, Chapter 18 of the United States Code, established rules and standards for the regulation of employee benefit plans, which include pension plans and employer-sponsored group health plans. Employer-sponsored group health plans that are subject to ERISA are regulated collectively by the U.S. Department of the Treasury Internal Revenue Service (IRS), the U.S Department of Labor (DOL) Employee Benefits Security Administration (EBSA) and the U.S. Department of Health and Human Services (HHS).  The following links provide more information about some of the most commonly referenced rules and regulations pertaining to employer-sponsored group health plans.

Code of Federal Regulations Title 29, Chapter XXV, Part 2590 - Rules and regulations applicable to group health plans

Code of Federal Regulations Title 29, Section 2560.503-1 – Additional rules promulgated by DOL establishing applicable standards for processing claims under group health plans

Consolidated Omnibus Budget Reconciliation Act (COBRA)

The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), among other things, established rules that allow employees to continue their coverage under an employer's group health plan after termination from employment (or another qualifying event). The following links provide more information about some of the most commonly referenced rules and regulations pertaining to COBRA benefits.

Code of Federal Regulations Title 29, Chapter XXV, Part 2590, Subpart A - Rule and regulations applicable to COBRA benefits and notice requirements

U.S. Department of Labor FAQs about COBRA premium assistance under the American Rescue Plan Act of 2021 

MEDICARE

Medicare was established under Title XVIII of the Social Security Act of 1965, which is codified under Title 42, Chapter 7, Subchapter XVIII of the United States Code.  Medicare provides health insurance coverage to individuals who are over age 65, disabled or diagnosed with End Stage Renal Disease (ESRD). The Medicare program is administered by the Centers for Medicare and Medicaid Services (CMS), a division of the U.S. Department of Health and Human Services (HHS).  The following links provide more information about some of the most commonly referenced rules and regulations pertaining to Medicare eligibility and coverage.

Code of Federal Regulations Title 42, Chapter IV, Subchapter B - Rules promulgated by HHS and CMS pertaining to the administration of Medicare

Medicare General Information, Eligibility and Entitlement Manual - CMS' operations manual regarding general program administration, eligibility and enrollment procedures

Medicare Benefit Policy Manual - CMS' policy manual regarding services and benefits covered under Medicare

Medicare Claims Processing Manual - CMS' policy manual regarding claims processing procedures, including rules for appealing denied claims

Medicare Managed Care Manual - CMS' policy manual regarding rules specific to Medicare Advantage (MA) plans

Medicare Prescription Drug Benefit Manual - CMS' policy manual regarding rules specific to Medicare Part D, Prescription Drug Plans (PDPs)

 

MEDICAID & CHIP

Medicaid was established under Title XIX of the Social Security Act of 1965, which is codified under Title 42, Chapter 7, Subchapter XIX of the United States Code. Medicaid is a medical assistance program for low-income individuals and families, which is administered jointly by the federal government and each individual state. The Children’s Health Insurance Program (CHIP) was established under the Balanced Budget Act of 1997, which is codified in Title 42, Chapter 7, Subchapter XXI of the United States Code. CHIP provides health care coverage to low-income children who do not qualify for Medicaid and who would otherwise be uninsured.

In Connecticut, the Medicaid and CHIP programs are collectively known as HUSKY. The Connecticut Department of Social Services (DSS) is responsible for overseeing and administering the HUSKY programs.

The following links provide more information about some of the most commonly referenced rules and regulations pertaining to HUSKY eligibility and coverage.

Code of Federal Regulations Title 42, Chapter IV, Subchapter C – Rules promulgated by HHS and CMS pertaining to the administration of Medicaid

Code of Federal Regulations Title 42, Chapter IV, Subchapter D – Rules promulgated by HHS and CMS pertaining to the administration of CHIP

CT General Statutes Title 17b, Chapter 319v - Connecticut state laws regarding Medicaid and CHIP medical assistance programs

Uniform Policy Manual - DSS policy manual establishing guidelines and procedures for determining eligibility and calculating benefits for HUSKY and other programs.

HUSKY A, C & D (Medicaid) Member Handbook - Plain language guide to benefits and services under HUSKY A, C & D (Medicaid) programs

HUSKY B (CHIP) Member Handbook - Plain language guide to benefits and services under HUSKY B (CHIP)