Consumer Protection in Private Health Insurance: The Role of Consumer Complaints. 1. Co-Ordination and Liaison


Jurisdiction and relationship with other government agencies:

  • What other agencies are involved in health insurance complaints in your state? Is there any involvement by the Health Department, Attorney General's Department, an Ombudsman, federal agencies including DOL and S-SHIP programs etc?
  • Have there been changes in terms of the responsibilities for complaints management across agencies? Describe those changes and the circumstances leading to the changes.
  • What does your Department do when it receives complaints for Medicaid and Medicare beneficiaries in your state? Is there any contact with Medicare Peer Review Organizations (PROs)?
  • What does your Department do when it receives ERISA complaints? Do you undertake any investigation/do you simply refer these onwards? What liaison do you have with federal agencies regarding ERISA complaints?
  • Are there any issues or problems with overlapping responsibility for managing health insurance complaints in your state that you particularly want to raise?
  • What is the current view about whether the complaints function in (name of state agency) should also be responsible for managed care issues? How do the Insurance Department and the Health Department manage the interface of regulating HMOs?
  • Has there been any interest expressed in the establishment of an ombudsman office? What has been the motivating factor?
  • Over which health insurance plans do you have jurisdiction? Is this a licensing function? Do you have responsibility for: indemnity plans, HMOs (commercial, all), PPOs, POS etc? Are the responsibilities and powers you have the same across all plans or do they differ? If so, can you describe how they differ?
  • Are there any types of health insurance plans which are not within your jurisdiction? Please describe these and any issues you have with them.

Relationship with health insurance plans/HMOs:

  • Do you require insurance plans or HMOs to submit complaints, grievance data or results of internal appeals processes regarding denial of care on a regular basis to your agency? If so, is this material publicly accessible and in what format? (e.g. your agency's annual report, web site, brochures, other?) (seek copies)
  • If plans submit data on complaints received directly by them, what is the quality of these data? Do you require plans or HMOs to conform to any standard reporting definitions in submitting these data?
  • Do you require insurance plans or HMOs to maintain complaints logs which may be accessed during market conduct examinations?
  • Do you require insurance plans or HMOs to submit details of their complaints management or internal grievance processes to you for approval? If so, what criteria do you use in approving these processes? Is there a legislative or regulatory basis for your involvement in oversighting plans/HMOs complaints and/or grievance processes?