Sec. 38a-479ee. Violations. Penalties. Investigations and staffing. Grievances. Referrals from Healthcare Advocate.
Sec. 38a-479ee. Violations. Penalties. Investigations and staffing. Grievances.
Referrals from Healthcare Advocate. (a) If the Insurance Commissioner determines
that a preferred provider network or managed care organization, or both, has not complied with any applicable provision of this part, sections 38a-226 to 38a-226d, inclusive,
or sections 38a-815 to 38a-819, inclusive, the commissioner may (1) order the preferred
provider network or managed care organization, or both if both have not complied, to
cease and desist all operations in violation of this part or said sections; (2) terminate or
suspend the preferred provider network's license; (3) institute a corrective action against
the preferred provider network or managed care organization, or both if both have not
complied; (4) order the payment of a civil penalty by the preferred provider network or
managed care organization, or both if both have not complied, of not more than one
thousand dollars for each and every act or violation; (5) order the payment of such
reasonable expenses as may be necessary to compensate the commissioner in conjunction with any proceedings held to investigate or enforce violations of this part, sections
38a-226 to 38a-226d, inclusive, or sections 38a-815 to 38a-819, inclusive; and (6) use
any of the commissioner's other enforcement powers to obtain compliance with this
part, sections 38a-226 to 38a-226d, inclusive, or sections 38a-815 to 38a-819, inclusive.
The commissioner may hold a hearing concerning any matter governed by this part,
sections 38a-226 to 38a-226d, inclusive, or sections 38a-815 to 38a-819, inclusive, in
accordance with section 38a-16. Subject to the same confidentiality and liability protections set forth in subsections (c) and (k) of section 38a-14, the commissioner may engage
the services of attorneys, appraisers, independent actuaries, independent certified public
accountants or other professionals and specialists to assist the commissioner in conducting an investigation under this section, the cost of which shall be borne by the managed
care organization or preferred provider network, or both, that is the subject of the investigation.
(b) If a preferred provider network fails to comply with any applicable provision
of this part, sections 38a-226 to 38a-226d, inclusive, or sections 38a-815 to 38a-819,
inclusive, the commissioner may assign or require the preferred provider network to
assign its rights and obligations under any contract with participating providers in order
to ensure that covered benefits are provided.
(c) The commissioner shall receive and investigate (1) any grievance filed against
a preferred provider network or managed care organization, or both, by an enrollee or
an enrollee's designee concerning matters governed by this part, sections 38a-226 to
38a-226d, inclusive, or sections 38a-815 to 38a-819, inclusive, or (2) any referral from
the Office of the Healthcare Advocate pursuant to section 38a-1041. The commissioner
shall code, track and review such grievances and referrals. The preferred provider network or managed care organization, or both, shall provide the commissioner with all
information necessary for the commissioner to investigate such grievances and referrals.
The information collected by the commissioner pursuant to this section shall be maintained as confidential and shall not be disclosed to any person except (A) to the extent
necessary to carry out the purposes of this part, sections 38a-226 to 38a-226d, inclusive,
or sections 38a-815 to 38a-819, inclusive, (B) as allowed under this title, (C) to the
Healthcare Advocate and (D) information concerning the nature of any grievance or
referral and the commissioner's final determination shall be a public record, as defined
in section 1-200, provided no personal information, as defined in section 38a-975, shall
be disclosed. The commissioner shall report to the Healthcare Advocate on the resolution
of any matter referred to the commissioner by the Healthcare Advocate.
(P.A. 03-169, S. 5; P.A. 05-102, S. 6.)
History: P.A. 05-102 amended Subsec. (c) by renaming the Office of Managed Care Ombudsman the Office of the
Healthcare Advocate and making conforming changes.