Consumer Protection in Private Health Insurance: The Role of Consumer Complaints. Methodology


A sample of six states (California, Maryland, New York, Oregon, Texas and Vermont) was selected based on a review of the web sites of all 50 states and discussions with experts in health insurance regulation. The six states were selected to represent a range of jurisdictional responsibility for health insurance complaints and the existence of ombudsman programs, together with states representing best practice in publication of health insurance complaints report cards. In four of the six states (California, Maryland, Texas and Vermont) ombudsman programs operate independently of the insurance regulatory agency. Four states (California, Oregon, New York, Texas) publish health complaints report cards for consumers which provide comparative data across health plans.

In each state key officials were identified who had regulatory responsibility for health insurance complaints management, operated ombudsman programs and/or were involved in the production of complaints report cards. Using a written consent form, officials were invited to participate in this study through interviews conducted on a "background" basis. Appendix 1 includes the list of interviewees, but this report does not attribute comments to a specific person, instead including interviewee remarks and observations in summary.

In total, 22 state officials across 10 state-based agencies were interviewed using a standard questionnaire (Appendix 2). In two states (Maryland and New York) interviews were conducted in person, while in the remaining four states interviews were conducted by telephone. Only one of 11 agencies contacted, the California Department of Corporations, was not able to participate because of the timing of the study. The health insurance regulatory functions of the Department of Corporations are shortly to be transferred to the newly established California Department of Managed Care, and the workload associated with this transition precluded the involvement of staff of the Department of Corporations in this study. The 10 state-based agencies included 8 state government agencies and two private sector agencies, the California Center for Health Care Rights and the Vermont Office of Health Care Ombudsman.

Telephone interviews were also conducted with the employee benefits staff of three major employers (Caterpillar, DaimlerChrysler and Motorola) to ascertain their role in complaints management. Appendix 3 is the standard questionnaire used in employer interviews.

All interviews (including both state officials and employers) occurred between October 1999 and April 2000. Interviewees were sent draft excerpts of the report relating to their interview to ensure accuracy. While interviewee comments have been incorporated in this report, any remaining errors are the responsibility of the author alone.

Relevant written materials were identified and analyzed including a position paper on consumer complaints by the National Association of Insurance Commissioners (the peak association for state insurance regulators), materials produced by state regulators including complaints report cards, annual reports, circulars, data collection reporting frameworks and press releases, and the academic literature on consumer comprehension of report cards. Appendix 4 is the listing of state-specific attachments, which are provided as a separate volume to this report, while Appendix 5 is the list of other references.