Unlike some states where health departments have a role in the quality regulation of HMOs, the Oregon Insurance Division has full jurisdiction over both traditional indemnity health plans and HMOs. The Oregon legislation uses the term "Health Care Service Contractors" for a HMO or other type of health insurance plan that contracts with doctors, ho
The organization of health insurance complaints management in Oregon is relatively straightforward, compared to most of the other states studied. The lead agency is the Department of Consumer and Business Services. Within the Department's Insurance Division, the Consumer Assistance Unit is directly responsible for consumer complaints.
The Department's Consumer Services Bureau has 107 allocated staff, 34 of whom are clerical support staff. While some specialize in health insurance, others work across multiple lines of insurance business. In addition to its 1-800 hotline, the Department maintains offices in several cities including New York City, Albany, Buffalo an
The Department of Insurance produces a wide range of consumer publications on health insurance. In addition to the New York Consumer Guide to Health Insurers described in the previous section, other significant publications include:
The complaints reports produced by the New York Department of Insurance are among the most comprehensive of any of the states included in this study. Attachments 2 & 3 provide copies of the 1999 and 1998 reports respectively, which each include data for the previous calendar year. Both the 1998 and 1999 reports are examined as t
While the Department of Health handles quality of care complaints and licensing, the Department of Insurance still has regulatory responsibility for all types of health insurance including: indemnity insurance, HMOs and POS plans). Moreover, self-insured plans are outside the Department's jurisdiction, with some of these plans contracting with PPO
The MIA has published a brochure titled "Need help with your HMO" which provides advice on the new Appeals & Grievances Law legislation and includes contact information for the MIA. The MIA website does not list any other health insurance publications.
The HEAU produces a range of brochures, guides and consumer tips includ
Scope - The report includes data from both the MIA and the HEAU on total health insurance complaints and grievances, covering between the first six to twelve months of operation of the new Appeals and Grievances Law. Complaints data in the report include a hierarchy of complaints management as follows:
The Maryland Health Care Commission (HCC), a public regulatory body established by the legislature, produces annual consumer report cards on HMO quality using HEDIS and CAPHS measures. The HCC produces three major types of reports:
The MIA does not publish regular reports directed specifically at consumers including comparative health insurance complaints data , similar to most of the other states in this study. In April 2000 the MIA issued a report focussing specifically on the operation of the new appeals and grievance law, but it has not published broader
The MIA operates under two sets of legislation, one applying to the whole insurance industry and the other applying specifically to HMOs. These laws have different penalties, although there are moves under way to make the laws, including the penalties, more similar.
In Maryland two agencies - the Maryland Insurance Administration and the Health Education and Advocacy Unit in the Office of the Attorney General - have the major role in managing health insurance complaints, while the Health Care Access and Cost Commission produces comparative report card information on HMOs.
The Department of Insurance Consumer Services Hotline has about 60 staff, including supervisors and clerical staff, working across all lines of insurance. The staff are organized into 5 teams of 10 staff with a supervisor, with regular supervisor meetings to examine emerging health complaints or patterns of complaints. In addition,
The Department of Insurance produces a number of general brochures related to health insurance and long term care. Since 1995 the Department has strengthened its efforts to improve the consumer friendliness and comprehensibility of these publications.