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4. Grievances (internal complaints received by

Consumer Protection in Private Health Insurance: The Role of Consumer Complaints. 4. Grievances (internal complaints received by health insurance plans) are a potentially rich data source in examining the implementation of patient protections. In five of the six states regulators stipulate the framework for grievance data that insuranc

Table 10.4 outlines the management and reporting of grievances in the six states studied. The NAIC Consumer Complaint White Paper does not refer to grievances managed directly by insurance plans and hence is not included in this table. The term “grievance” is used in this report to mean any complaint made by a consumer directly to a health ins
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3. The existence and standard of consumer “report

Consumer Protection in Private Health Insurance: The Role of Consumer Complaints. 3. The existence and standard of consumer “report cards” on health insurance complaints vary substantially. There are some good examples of best practice, but some reports are overly complex and provide insufficient guidance to consumers.

An NAIC survey of state insurance regulators undertaken in 1999 found that only 26 states affirmatively published complaint information “in either an annual report, consumer brochure or on the Department’s web site”. Readers are reminded that the four states with published reports (California, Oregon, New York and Texas) discussed below repr
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2. There is a wide spectrum in the type of

Consumer Protection in Private Health Insurance: The Role of Consumer Complaints. 2. There is a wide spectrum in the type of consumer assistance or ombudsman programs available to people with complaints about health insurance.

Table 10.2 identifies the different models of consumer assistance or ombudsman programs and their major features in the five states with such programs (New York being the exception). The NAIC Consumer Complaint White Paper is essentially silent on the role of ombudsman programs and is hence not included in this table.
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1. Jurisdiction over health insurance complaints

Consumer Protection in Private Health Insurance: The Role of Consumer Complaints. 1. Jurisdiction over health insurance complaints varies across states, with responsibility for indemnity health insurance, HMOs and quality complaints often split within or between state agencies.

Table 10.1 indicates that in three states (Oregon, Texas and Vermont) a single government agency has the major regulatory responsibility for health insurance complaints management. However in the other three states (California, Maryland and New York), responsibility for indemnity health insurance, HMOs and quality complaints is split across two go
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Conclusion

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

Findings, Policy Implications and Recommendations Based on interviews with state health insurance regulators and ombudsman staff and an analysis of documents, some interesting lessons emerge from the experience of the six states in operating health insurance complaints systems.
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Conclusion

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

Across the three employers interviewed for this study, complaints about health insurance were most likely to be used to reassess coverage decisions. None of the employers interviewed were able to provide complaints data which might shed some light on the pattern and volume of complaints, including the range of complaints related to patient protect
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Motorola

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

Motorola provides health insurance for its employees on a self-funded, self-administered basis. The distribution of staff in various plan types is as follows: 16% in 23 HMOs; 6% in managed indemnity; 6% opt out and do not have Motorola-provided insurance; and 72% are in a custom designed program to improve the clinical quality of service
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DaimlerChrysler

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

DaimlerChrysler offers its U.S. employees and retirees (hereafter referred to as participants) a  range of health insurance options  including traditional indemnity insurance and PPO packages (both self-funded) and HMOs (fully insured, with DaimlerChrysler paying on a capitated basis).
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Caterpillar

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

Caterpillar provides health insurance through a self-funded, self-administered plan for about 40,000 employees or 150,000 covered lives in the U.S. Unlike many large employers, Caterpillar does not use tightly managed care gatekeeper plans. It provides a PPO plan for about 85% of its employees not in a HMO; the balance are in an indemnity plan. In
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Employers

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

The survey undertaken for the California Managed Health Care Improvement Taskforce indicated that 17% of insured people with a problem contacted their employer benefits office for assistance, the third most common source of assistance after health insurance plans and medical providers. Given this, and the fact that the vast majority of privately i
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E. Agency Performance Issues

Consumer Protection in Private Health Insurance: The Role of Consumer Complaints. E. Agency Performance Issues

Staffing In the DHCA there is one Consumer Services Specialist with responsibility for the Hotline, although consultation may occur with other staff as required for guidance, including legal staff. The Ombudsman Office has a total of 4 and 1/2 staff, together with the Ombudsman. These staff cover all issues, including providing the Medicai
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D. Public Education Activities

Consumer Protection in Private Health Insurance: The Role of Consumer Complaints. D. Public Education Activities

Publications In addition to the toll-free line, the DHCA publishes a range of reports relevant to health insurance including:
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C. Complaints Reports and Data

Consumer Protection in Private Health Insurance: The Role of Consumer Complaints. C. Complaints Reports and Data

Neither the DHCA nor the Ombudsman Office publish complaints "report cards", comparing the complaints performance of individual plans. DHCA
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B. Jurisdiction and Liaison with Health Plans

Consumer Protection in Private Health Insurance: The Role of Consumer Complaints. B. Jurisdiction and Liaison with Health Plans

The Division of Health Care Administration, BISHCA When the DHCA receives a complaint about ERISA plans, it sends out a letter as though they are able to be regulated. Generally, these entities respond in a similar manner to regulated plans, with no-one ever refusing to respond because of the lack of regulatory authority by the DHCA for thes
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A. Jurisdiction and Responsibility for Consumer

Consumer Protection in Private Health Insurance: The Role of Consumer Complaints. A. Jurisdiction and Responsibility for Consumer Complaints Systems

Vermont is unusual among the states studied in that health insurance complaints are the responsibility of a health division, the Division of Health Care Administration, rather than an insurance regulatory agency. However the Division of Health Care Administration is a sister division to the Insurance Division in the Department of Banking, Insuranc
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Vermont

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

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E. Agency performance measures

Consumer Protection in Private Health Insurance: The Role of Consumer Complaints. E. Agency performance measures

Staffing
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D. Public education activities

Consumer Protection in Private Health Insurance: The Role of Consumer Complaints. D. Public education activities

Publications TDI publishes a range of brochures relating to health insurance including: Independent Review Organizations; Patient Protection Rules - Fair Play under Managed Care; Questions and Answers about your Health Care Coverage. Demand for Publications In 1999 TDI distributed 1.5 million copies of insurance related publi
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3. Insurance Company and HMO Profile Reports

Consumer Protection in Private Health Insurance: The Role of Consumer Complaints. 3. Insurance Company and HMO Profile Reports

Features The TDI produces HMO and indemnity health insurance company profiles which are available electronically. Data in the profiles are as follows:
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2. Comparing Texas HMOs Annual Reports

Consumer Protection in Private Health Insurance: The Role of Consumer Complaints. 2. Comparing Texas HMOs Annual Reports

Features Scope  - This report is comprised of two main sections. Firstly, it contains the results of the Consumer Assessment of Health Plans Survey (CAPHS) which was administered by an independent survey vendor certified by NCQA to a sample of Texas health plan recipients. Secondly, it contains data on consumer complaints about HMOs made t

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Form Approved OMB# 0990-0379 Exp. Date 9/30/2020