Content by Keyword: Consumer Protection and Patient Safety

Features Scope  - The report includes all complaints (but see next dot point) filed annually with the Health Plan Division about Health Care Service Plans, commonly referred to as HMOs. The Division groups health care service plans into full service, dental, vision, psychological and other. The Division's term for complaints is "requests f

Introduction The Task Force Survey was intended to document the extent and nature of difficulties Californians report with their health insurance plan. While not a comparative "complaints report card", it is included here as it provides some insights into the general pattern of problems or complaints. It is also useful in identifying the pro

In 1998 the  Managed Health Care Improvement Task Force  commissioned a one-off survey of insured Californians to assess the level and nature of their health insurance complaints and the processes used for dispute resolution (Attachment 4). While not strictly a “complaints report card”, it is examined here as it provides some background on t

Department of Insurance The Department of Insurance operates a consumer Hotline for inquiries and complaints which is essentially “the eyes and ears” of the Department. When the Hotline receives an inquiry or complaint, it does not immediately refer it onwards. The priority is to find out exactly what the problem is and help educate the

Overview Commensurate with its size and diversity, California has a range of public and private sector organizations involved in either health insurance complaints management and regulation, or the production of health insurance complaints report cards.

Staffing The Draft White Paper notes that although some complaints analysts may specialize by line of insurance, it is beneficial for all analysts to have "a basic understanding of all lines of insurance", particularly relevant to dealing with catastrophic situations. Consumer Satisfaction

Publication of Complaints Information

Definition of Complaints The NAIC proposes that best practice would incorporate including both written and oral complaints, with the distinction between complaints and inquiries being that a complaint includes the expression of a grievance. Consistency with NAIC Database

Oversight of Grievance Processes of Insurance Plans The Draft White Paper is totally silent as to whether state insurance departments should have any role with regard to requiring plans to: Submit internal complaints or grievance data; Maintain internal complaints logs; and Submit details of their internal complaints management proces

Legislative Jurisdiction

The National Association of Insurance Commissioners (NAIC) was established in 1871 and is the peak association comprising insurance regulators from the 50 states, the District of Columbia and the four U.S. territories. Since Spring 1998 the NAIC has been working on a Consumer Complaints White Paper concerning all lines of insurance. The Draft Wh

Following this introduction, the report commences by identifying the views of the National Association of Insurance Commissioners on complaints management. The next six chapters describe and analyze complaints management in the six states. This is followed by a discussion of the role of three major employers in complaints management. Finally, the

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 ombu

In 1999, the U.S. House of Representatives and the U.S. Senate passed legislation addressing patient protections under health care plans, with the bills still being considered in Conference Committee as at June 2000. This followed the passage of comprehensive patient bills of rights in some 39 states between 1994 and 1998, in response to growing c

The multiplicity of agencies involved in oversight of health insurance complaints makes it difficult to develop a comprehensive picture of how well insurance plans are performing on consumer complaints. However, the pursuit of uniform models of health insurance complaints management is not recommended at this time. Instead, it is recommended that

Jurisdiction over private health insurance complaints varies across states, with responsibility for indemnity health insurance, managed care and quality complaints often split within or between state agencies. The lead role is usually taken by state insurance regulatory agencies, with the contribution of state health agencies declining in several

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 ombu