State of Connecticut Person ID: 1367638

Health Insurance Exchange Doc ID: 35817588

Notice Date: 05/18/2023 Application Date: 05/18/2023

Ernest Woods Application ID: 11252581

56 Judson st
1st floor
Hartford, CT 06120

Subject – Health Care Coverage Renewal Decision Notice

Dear Ernest Woods,

A notice was sent to you detailing your right to make changes to your coverage. Since you have not chosen to
make a change or terminate your coverage, we will be renewing your eligibility for HUSKY (Medicaid/CHIP)
health care coverage.
Please read this entire notice. You have the right to appeal the decision(s) on this notice. This notice has
important information about your eligibility and appeal rights.

Your household’s new eligibility determination is detailed below.

Your Eligibility Determination

Eligible Individuals:
HUSKY D - Adult Begin Date
Ernest Woods 06/01/2021
Attention newly eligible Medicaid members and Medicaid Enrolled Providers: For a period of 45 days from the
date of this notice, this notice serves as proof of Medicaid coverage. This temporary notice guarantees
payment to the Medicaid enrolled provider when providing health care services. It only guarantees payment for
medically necessary goods and services that are covered by Medicaid. Providers are encouraged to verify the
identity of the individual before rendering goods or services to the member. Eligibility status with client
identification number will be updated in the Automated Eligibility Verification System within 45 days.

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How to Renew Your Coverage/Report a Change

Please follow the steps listed below if you wish to make any changes to your coverage or select a new plan.
You must complete these steps during the Open Enrollment period, from 11/01/2023 to 01/15/2024.

• Log in to your Access Health CT account at www.accesshealthct.com

• Click the “Report a Change/Renew Coverage” from your account home screen
• Review and confirm that each applicant’s information is accurate
• Report any changes necessary
• Provide your electronic signature and SUBMIT
• Select a plan and COMPLETE THE ENROLLMENT PROCESS

If you do not wish to renew online, you may also renew your coverage during the 2023 Open Enrollment period
by contacting Access Health CT (see How to Contact Access Health CT below).

Appeal Rights
If you think we made a mistake deciding that you are no longer eligible for a health care program, you have the
right to appeal and ask for a hearing. For information on how to appeal, see the Appeal Rights and Deadlines
section of this notice.
MEDICAID and CHIP (HUSKY A, B OR D) only: If you want to appeal our decision to end your eligibility for
Medicaid (HUSKY A or HUSKY D) and/or CHIP (HUSKY B), you can keep your coverage while you appeal. If
you ask for a hearing before that date, your coverage will stay in place until a decision is made on your appeal.
Other Help Available
If you agree with our decision that you are not eligible for your current health care coverage, and do not want to
appeal, you may be able to get other types of help:

Other Medicaid Coverage Groups

If any member of your household is aged, blind, disabled or in need of long term care, please visit
www.connect.ct.gov to see if anyone is eligible for another Medicaid coverage group.

QHP – Qualified Health Plans

If you are no longer eligible for Medicaid or CHIP, you may qualify for financial help enrolling in a Qualified
Health Plan (QHP). This may include: 1) tax credits to help you pay your monthly QHP premiums; 2) cost
sharing reductions that lower your out-of-pocket health care expenses; or both.

To find out if you qualify to enroll in a QHP with financial help, refer to the How to Apply for Enrollment in a
QHP section below.

Other QHP Programs

If you are no longer eligible for financial help with your QHP but you still want to be covered in a health plan,
you may qualify for coverage in a QHP without financial help (see How to Apply for Enrollment in a QHP
section below)

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Health Insurance Exchange Doc ID: 35817588

How to Apply for Enrollment in a QHP

If you want to apply for Enrollment in a QHP, please follow the steps listed below:
1. Login to: www.accesshealthct.com
2. Call the Access Health CT Call Center 1-855-805-HEALTH (1-855-805-4325) or, for those individuals
who are deaf or hard of hearing, the TTY number 1-855-789-2428

If you choose to apply online through www.accesshealthct.com, you may do the following:
• Log in to your Access Health CT account at www.accesshealthct.com
• Click the “Report a Change” from your account home screen
• Check the box ”Gain or loss of public or employer sponsored minimum essential coverage” from the
“Reason for Changes” screen
• Proceed to the Change Reporting application process to report the loss of your previous health
coverage program
• Provide your electronic signature and SUBMIT
• Select a plan and COMPLETE THE ENROLLMENT PROCESS

If you do not take any actions within 60 days from the loss of the health coverage, you will not be
qualified to purchase a Qualified Heath Plan (QHP) until the next Open Enrollment period.
If any member of your household has turned 26 years old and is no longer eligible for coverage as a
dependent, or has turned 30 years old and is no longer eligible for coverage in a catastrophic plan without an
Access Health CT granted affordability or hardship exemption, this person must contact Access Health CT
(see How to Contact Access Health CT below) to apply for coverage for the upcoming 2023 coverage year.

How to Contact Access Health CT

Contact Access Health CT if you need to report changes, select a plan or program or have any questions
about this notice. Let us know if you need help applying for health or dental coverage or accessing your
account. You can contact Access Health CT:
• Online at www.accesshealthct.com or
• By calling the Access Health CT Contact Center 1-855-805-HEALTH (1-855-805-4325) or, for those
individuals who are deaf or hard of hearing, the TTY number 1-855-789-2428

If you have a disability you may request and receive a reasonable accommodation or special help from Access
Health CT, when it is necessary to allow you to apply for and receive services through Access Health CT.

Sincerely,
Access Health CT

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Health Insurance Exchange Doc ID: 35817588

Appeal Rights and Deadlines

You have the right to a hearing if you disagree with any decision(s) we have made regarding your benefits
coverage.
• For Medicaid and CHIP (HUSKY Health) decision(s), you have 60 days from the date of this notice to
request a hearing. If you do not request a hearing within 60 days you may lose the right to a hearing.
• For all other decision(s), you have 90 days from the date of this notice to request a hearing. If you do
not request a hearing within 90 days you may lose the right to a hearing.
• For assistance with the Appeals process, please contact the Office of the Healthcare Advocate:

o By Phone: (866) 466-4446; or email your request

o By email: Healthcare.Advocate@ct.gov

How to Appeal Decisions on Subsidies or HUSKY Health

If you disagree with a decision made on your subsidies or HUSKY Health programs, you may ask for a hearing
in one of the following ways. Complete the Appeal/Hearing Request Form included with this notice and:
• Mail at Department of Social Services, Office of Legal Counsel, Regulations and Administrative
Hearings, AHCT-DSS Hearings Unit, 55 Farmington Avenue, Hartford, CT 06105-3725
• Email to DSS-AHCT@ct.gov
• Or by calling (855) 306-8625

How to Appeal Decisions on Eligibility to Buy Insurance

If you disagree with the decision that you are not eligible to buy insurance through Access Health CT, you may
ask for a hearing in one of the following ways. Complete the Appeal/Hearing Request Form included with this
notice and:
• Mail to PO BOX # 670, Manchester, CT 06045-0670
• Or by calling (855) 805-4325

How to Request Expedited Appeals

You may ask for an expedited (quicker) hearing if the regular decision deadlines put your life or health at
serious risk or could seriously affect your ability to function. You or your health care provider must show us
why you need an expedited hearing. If an expedited hearing is needed, we will make our hearing decision no
more than three business days after we receive your request.

You may request an expedited hearing by doing one of the following below.
• By calling (855) 306-8625
• By mail at Department of Social Services, Office of Legal Counsel, Regulations and Administrative
Hearings, AHCT-DSS Hearings Unit, 55 Farmington Avenue, Hartford, CT 06105-3725
• By email @ DSS-AHCT@ct.gov

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HEARING/APPEAL REQUEST FORM

Use this form only if you want a hearing. Remember: Before you ask for a hearing, you may call 1-855-805-
HEALTH (1-855-805-4325) to see if we can help you without the need for a hearing.
Please fill out the form below. Fields marked with an asterisk (*) are required.
Name*:
Application ID (located in the upper right corner of your Eligibility Decision for Healthcare Coverage notice) *:
Address (Street, City, State, Zip Code) *:

Daytime Phone number (including area code) *:

Email:
Will you need a translator for the hearing?* No Yes
If yes, what language do you speak?
We usually hold hearings by telephone. You may also have a hearing by video conference from a DSS
regional office. Please check how you want your hearing*: By telephone By video conference at DSS

The amount of my premium with [APTC] is not correct.

Medicaid or CHIP has been denied or terminated.
A member or members included in my household are not correct.
The amount or the type of income that was used to determine my eligibility is not correct.
The immigration/citizenship status of a household member is not correct.
The Exchange eligibility was incorrectly denied.
The American Indian status of a household member is not correct.
The employer sponsored minimum essential coverage (MEC) or other MEC was incorrect.
HUSKY Only: If you were getting HUSKY A, D or B (Medicaid or CHIP) medical benefits and you ask
for a hearing about the decision on your medical benefits any time before the change becomes
effective, your medical benefits will stay as they were until the Hearing Officer decides your case.

Please check this box if you want to keep your health care coverage the way it was before
AHCT’s decision and until the Hearing Officer decides your case.
Other reason – please explain:

Signature: Date:
Is someone helping you with this appeal? (For example, this could be a friend, family member, an attorney,
someone else) Yes No If yes, please provide this person’s contact information:
Name:
Phone:
Address:
Email:

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Access Health CT Privacy Policy

Access Health CT is a new health insurance marketplace developed by the State of Connecticut to satisfy the
requirements of the federal Patient Protection and Affordable Care Act (the “ACA”). This Privacy Policy
describes our policies and procedures regarding our collection, use and disclosure of the personal information
that we receive in the course of our activities. Our collection, use and disclosure of personal information are
regulated by applicable federal and state law, including, without limitation, the regulations created by the
federal Department of Health and Human Services under the ACA.

How We Collect Information

Information You Choose to Share

Primarily, we collect personal information that you voluntarily provide to us. For example, when you register on
the Access Health CT website for a User ID and password, we request that you provide your name and email
address. If you use our website to learn more about or enroll in one of our available plans or programs, we may
request additional information from you, including additional contact information (such as your address and
phone number), demographic information (such as your age, gender and annual income), your Social Security
number or other government-issued ID number, information regarding your employer, and similar information
about the members of your family. We may also collect similar personal information from you in person through
one of our assistors, navigators or brokers, or at one of our exhibits or offices, or through one of our call
centers.

As discussed below, we may also supplement the information we collect with information we receive from other
federal and state government agencies (such as the IRS, Medicare, Medicaid and the Connecticut Department
of Social Services) as well as private information clearinghouses.

Information Collected Automatically

• Log Files
When you use our website, our servers automatically record information that your browser sends whenever
you visit a website. These server logs may include information such as your Internet Protocol (IP) address,
browser type, browser language, the date and time of your request and one or more cookies that may uniquely
identify your browser. This information is periodically deleted as part of normal maintenance routines.

• Cookies
Cookies are small text files stored on your computer by a website that assigns a numerical user ID and stores
certain information about your online browsing. We use cookies on this site to help us recognize you as a prior
user. No personal information is stored on any cookie that we use. If you wish, you can adjust your web
browser’s privacy settings to delete cookies upon exiting websites or when you close your browser. You may
also configure your browser to block cookies; however, doing so may negatively impact your user experience.

• Digital Fingerprinting
We use digital fingerprinting technology, also known as "machine identification" technology, to gather certain
data about you and/or your computer. This identification number is based on data that is automatically
transmitted by your browser, such as your IP address and computer operating system and browser version
number. This technology creates a unique computer identifier which may be used by Access Health CT to
identify your device, which will allow us to improve the user experience, better safeguard your personal
information, and to protect the integrity of the enrollment process.

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How We Use and Disclose Personal Information

We use your information for the purposes of providing our services – helping you determine your eligibility for
participation and enrolling in qualified health plans and relevant health insurance affordability programs. We
may also use your information (i) to support our internal operations and the improvement of our website and
services, (ii) to comply with applicable law, and (iii) to communicate with you, including responding to your
inquiries. We may also use information that you provide to us, in combination with information that we receive
from the sources described below, to directly contact you to inform you regarding health plans and programs
that you may qualify for.

We do not sell any of your personal information that we collect through this website or otherwise received by
Access Health CT. We may disclose your personal information to employees and agents of Access Health CT
with a need to know in the course of performing services on behalf of Access Health CT. We require these
employees and agents to keep your information confidential and to use your personal information only in the
performance of services for Access Health CT. In addition, in order to verify and supplement the personal
information we receive from you, we may disclose personal information you provide to us to several state and
federal government agencies, including, without limitation, Medicare, Medicaid, the IRS, the Connecticut
Department of Social Services and the Connecticut Department of Revenue Services, as well as to private
data clearinghouse firms.

Information that we automatically collect through our website is used to improve our website and the user
experience, better safeguard your personal information, and to protect the integrity of the enrollment process.

In the event Access Health CT is merged into any other state or federal agency, Access Health CT may
disclose your personal information to such successor agency and such successor agency may use your
personal information for the purposes contemplated in this Privacy Policy.

Safeguards We Have Implemented to Help Ensure the Security of Your Personal Information

The security of your personal information is very important to us. We have put in place reasonable operational,
administrative, technical and physical safeguards to protect the information we collect, as required by
applicable law. We cannot guarantee, however, that all communications between us or information stored on
our servers will be free from unauthorized access by third parties, such as hackers.

How Can You Review and Correct Your Personal Information That We Have Collected, Used or
Disclosed

We will make available to you the personal information in our custody or control that we have collected, used
or disclosed, upon your written request, to the extent required and/or permitted by law.

You can access your User ID profile information by logging into the www.accesshealthct.com, Account Home.
To request any other personal information that we hold about you, please submit your request in writing at the
email address or postal address shown below in the Contact section. When we receive an access request from
an individual, we will attempt to fulfill your request within 30 days. For your security, we may request additional
verification of your identity before providing any information. In certain circumstances, we may not be able to
give you access to all of your personal information. This may occur, for example, where revealing personal
information to you may also reveal personal information of a third party or where the information has been
collected for the purposes of a legal investigation. We make reasonable efforts to keep personal information
in our possession or control accurate and complete, based on the most recent information available to us.

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We also, however, rely on you to keep your personal information accurate and complete. If you register with
us, you have the right, and we encourage you, to view and update your registration information at any time. To
update your information, please log into the www.accesshealthct.com, Account Home or email us at
questions@accesshealthct.com. If you believe your personal information is inaccurate, you can demonstrate in
writing the inaccuracy or incompleteness of the personal information we have on you. If you successfully
demonstrate that the personal information we have on you is inaccurate or incomplete, we will amend it as
required.

Changes to this Policy

We reserve the right, at our discretion, to modify our privacy practices and update and make changes to this
Privacy Policy at any time. This Privacy Policy is current as of the “last revised” date which appears at the top
of this page. We will treat personal information in a manner consistent with the Privacy Policy under which it
was collected, unless we have your consent to treat it differently. By using this website following any Privacy
Policy change, you freely and specifically give us your consent to collect, use, transfer and disclose your
personal information in the manner specified in our then-current Privacy Policy.

Links to Third Party Websites

This Privacy Policy applies solely to this website and the services provided by Access Health CT, and not to
any other product or service. This website may contain links to a number of third party websites that we believe
may offer useful information. The policies and procedures we describe here do not apply to those websites.
We recommend that you carefully read the privacy policies of each site that you visit for information on their
privacy, security, data collection and distribution policies.

How to Contact Access Health CT

If you have questions, comments or suggestions, please e-mail us at Questions@accesshealthct.com in the

US or call us at (855) 805-4325.

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CONNECTICUT DEPARTMENT OF SOCIAL SERVICES (“DSS”)

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND
HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Effective Date of this Notice: September 23, 2013

THIS NOTICE APPLIES ONLY TO DSS HUSKY HEALTH PROGRAMS (MEDICAID & CHIP)

Q. Does DSS disclose my protected health information with others?

A. DSS may share health information about you before we pay providers for your treatment and services; to
see if you are eligible for other services from DSS; and to operate the Medicaid, HUSKY and other DSS
programs. This includes looking into possible fraud by or overpayments to providers and defending DSS in
lawsuits. For example, we may share your health information with the following:

• professionals we hire to see if your treatment is necessary and if we can pay for it;
• companies we contract with to help run our programs, pay medical bills and find out if you are eligible
for any other health benefit programs;
• providers or agencies, if necessary to help you get benefits from DSS;
• medical providers and other individuals and entities to make sure you are getting the most appropriate
treatment and benefits; and
• health insurance companies we bill if DSS has paid for services that those companies should have paid for.
We may also share your health information, without your approval, in an emergency, in response to a court
order or when the law requires that we share it. For example, the law may require that we share your
information with:
• the Labor Commissioner if it is directly related to unemployment compensation or to serve certain
people receiving help from DSS;
• the Commissioner of Mental Health and Addiction Services when necessary to operate some of its
programs;
• the Commissioner of Administrative Services or Emergency Services and Public Protection to collect
overpayments or amounts owed to DSS; to investigate fraud; and to locate absent parents of children
who are on benefits;
• the Commissioner of Children and Families if there is immediate danger to a child’s health or safety or
the Department of Public Health to coordinate certain benefits;
• other state agencies, the police, or the federal government.

Q. Does DSS need my approval before it shares my protected health information?

A. When you applied for benefits from DSS, you agreed that DSS could share your information for purposes of
operating its programs and paying for your benefits. We need your separate approval to share information
about you that is not related to payment of claims, treatment, or operating the programs that you are on, except
if the law requires us to share it. For example, we would usually need you to agree in order for DSS to give out
any psychotherapy notes we have about you. If we wanted to use or give out protected health information
about you for marketing purposes or if we were to sell your protected health information, we would also need
you to agree. Even if you give your approval for us to give out your information, you may change your mind as
long as you do so, in writing, before we have given it out.

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Q. What are DSS’s duties?

A. DSS is required by law to keep your protected health information private, to provide you with notice of our
legal duties and privacy practices concerning your protected health information and to notify you following a
breach of unsecured protected health information. DSS must also follow all of the rules listed in this notice and
send or give you a new notice if we make important changes to our privacy rules and practices. DSS reserves
the right to change its privacy practices. If the privacy practices change, DSS will send you a new notice. The
new privacy practices will apply to the information DSS already has about you.

Q. What are my rights?

A. You have the right to:

• have a paper copy of this notice, upon request, even if you got it electronically;
• ask us to limit uses and sharing of your information to carry out treatment, payment or health care
operations, although the only time we must follow your wishes is if you ask us not to disclose such
information to another health plan about a health care item or service that you paid for yourself;
• an accounting. DSS keeps a list of persons or agencies we have given your protected health
information to if you did not ask us to share it or if we shared it for reasons other than payment,
treatment or operation of our programs. You may get that list for 6 years back from the date you ask for
it;
• ask us to contact you in a special way. For example, you may ask us to contact you at work or by mail
only;
• look at and copy, upon written request, the health information we have about you, except if we think it
would be harmful to you; if the information was collected for use in a civil or criminal proceeding; or you
would learn the names of people who gave us information about you without your knowing it and we
agreed not to share those names with you;
• ask us to change information we have about you in your DSS record. You must ask us in writing and
state the reason you are asking for the change. We may not agree to change the information in your
record.

We may contact you about your appointments, treatment alternatives or health-related benefits and services.

Q. What if I have questions?

A. If you have questions about privacy concerning your health information, need this notice provided in an
alternative format, or wish to exercise your rights as stated above, you may call the DSS Privacy Officer at the
DSS Central Office at 1-888-760-8883 or email PrivacyOfficer.dss@ct.gov.

Q. What if I think DSS shared my information incorrectly?

A. You may complain by writing to the DSS Privacy Officer at 55 Farmington Avenue, Hartford, CT 06105-9902
or by emailing to PrivacyOfficer.dss@ct.gov. You may also complain to the Boston office of the federal Office
for Civil Rights, U.S. Department of Health and Human Services, J.F. Kennedy Federal Building, Room 1875,
Boston, MA 02203, or email OCRComplaint@hhs.gov within 180 days of when the problem happened. Your
benefits will not be affected if you make a complaint.

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Access Health CT
PO BOX # 670
Manchester, CT 06045-0670

IMPORTANT: YOU MUST INCLUDE THIS COVER SHEET WITH ALL DOCUMENTS RETURNED TO
ACCESS HEALTH CT.

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