Key points
- A state consumer advocate is a free helper, sometimes a state office and sometimes a nonprofit, that explains your plan and your appeal rights and may prepare your appeal.
- Availability varies by state. Some states have a strong program, some a small one, and some very little.
- A state program can usually help with insured plans. For a plan your employer pays for itself, state insurance law generally does not apply, so ask the program what it can still do and call the Department of Labor.
- Calling an advocate does not stop your appeal deadline.
If your state has a consumer advocate, call it early. These programs are free, and some of them will write and file the appeal for you. Whether your state has one, and what it does, varies. Check your state page, and use the three examples below to know what good help looks like.
What this means
A state consumer advocate may go by different names: an office of the health care advocate, a consumer assistance program, or an ombudsman, which means a person who takes complaints on behalf of the public. Federal rules and HealthCare.gov use the term consumer assistance program. HealthCare.gov says your state’s program can file an appeal for you, and a plan that is not grandfathered must put the contact details for any state consumer assistance program on its denial notices. The Centers for Medicare & Medicaid Services keeps a page that links to each state’s consumer assistance program contacts. The page was last updated in September 2024, so confirm the contact before you call.
Three examples show the range. They are examples, not a ranking.
- Connecticut. The Office of the Healthcare Advocate is an independent state agency. It is free to all Connecticut residents whatever their insurance. Its advocates explain benefits and prepare and file appeals of denials and prior authorization refusals. Since 1 January 2023, Connecticut law requires insurers to print an approved message on the first page of denial notices telling members to contact the office for free help. Phone 1-866-466-4446, Monday to Friday, 8:00 a.m. to 4:30 p.m.
- New York. Community Health Advocates is a nonprofit run by the Community Service Society of New York. It says the state designated it as New York’s health care consumer assistance program in 2010. It runs a staffed helpline, (888) 614-5400, Monday to Friday, 9:00 a.m. to 4:00 p.m., and a network of 24 local partner organizations, and publishes do-it-yourself appeal packets by denial reason.
- Vermont. The Office of the Health Care Advocate is a project within Vermont Legal Aid, a nonprofit law firm, and is not part of state government. It helps Vermonters with any kind of coverage and runs a helpline, 1-800-917-7787, Monday to Friday, 8:30 a.m. to 4:30 p.m.
Hours and numbers change, so confirm them on the program’s page before you call.
What to do
- Find your state’s program (your step). Open your state page or use the find help tool. Check your denial notice too, because it should list the contact.
- Ask whether your plan is insured or self-funded. If an insurance company bears the cost, the state program can usually help. If your employer pays claims itself, state insurance law generally cannot be applied. See self-funded or fully insured.
- Call or send the form with the facts ready. Have the denial letter, the claim number, the plan name, the deadline and what you want. The call script for the regulator is a good start.
- Ask what the advocate can do. Ask whether the office will file the appeal, call the plan, or only explain your rights. Ask what they need from you and by when. Write down the name of the person you spoke to.
- Give written permission if they will act for you. The advocate may need a form that names it as your representative. See acting for someone else.
- Keep your own deadline. Ask the advocate for the date they are working to, and keep your own record. Check the date on your notice, which controls.
- If there is no state program, use the next best helper. See where to get free help, including the state insurance department and legal aid.
What the program may say, and what to say back
“We only help with insured plans.” My plan is paid by my employer. Please tell me what you can still do, and which office handles self-funded plans.
“We are at capacity.” Can you tell me when to call back, or refer me to a partner organization? I will keep my appeal deadline on my own.
“We can give you a template.” That helps. Can someone review it with me, and can you tell me who to send it to?
The rule
A non-grandfathered plan or insurer must include, in a denial notice, contact details for any state consumer assistance program or ombudsman, and how to start internal appeals and external review. See Code of Federal Regulations (CFR), title 29, section 2590.715-2719(b)(2)(ii)(E).
Watch for
- Big differences between states. This page describes one state agency, one nonprofit and one legal aid project. Another state may offer something much smaller, or nothing.
- Not the same as a lawyer. An advocate explains your rights and helps you file. Ask each program whether it can represent you at a hearing or in court. See legal aid.
- A complaint is different from an appeal. Ask the advocate which they are filing.
- Medicare and Medicaid. These have their own helpers. See Medicare counseling.
What next
- Where to get free help, by coverage type: the full map.
- Complain to the state insurance department: when a regulator complaint makes sense.
- Find free help: all the pages on this topic.