Prepared by: RAND Health working paper series CHERYL L.DAMBERG, MELONY SORBERO, ATEEV MEHROTRA, STEPHANIE TELEKI, SUSAN LOVEJOY, AND LILY BRADLEY Prepared for: Office of the Assistant Secretary for Planning and Evaluation (ASPE) U.S. Department of Health and Human Services (HHS) Prepared Under: WR-474-ASPE/CMS
Consumer Protection in Private Health Insurance: The Role of Consumer Complaints. Appendix 5 - References
Bodenheimer T “California’s Beleaguered Physician Groups – Will they survive?” New England Journal of Medicine , 2000, 342(14):1064-1068 Brewster LR, Jackson L and CS Lesser “Insolvency and Challenges of Regulating Providers that Bear Risk”, Issues Brief , Center for Studying Health System Change, February 2000, Number 26 Gorml
Consumer Protection in Private Health Insurance: The Role of Consumer Complaints. Appendix 4 - List of NAIC and State Attachments
Attachments - NAIC 1. National Association of Insurance Commissioners, Consumer Complaint White Paper , Draft of 13 March 2000 Attachments – California
Consumer Protection in Private Health Insurance: The Role of Consumer Complaints. Appendix 3 - Interview Questionnaire Employers
1. Do you get involved when your employees have a specific complaint about a health plan, as distinct from general information inquiries about benefit coverage or eligibility? 2. What is the nature of your involvement in employee complaints about health plans? Do you ring, write or fax the health plan? Is there a nominated contact in the health
Consumer Protection in Private Health Insurance: The Role of Consumer Complaints. 1. Co-Ordination and Liaison
Jurisdiction and relationship with other government agencies:
Consumer Protection in Private Health Insurance: The Role of Consumer Complaints. Appendix 1 - List of Interviewees
California Judy Penman Supervisor Hotline Consumer Communications Bureau California Department of Insurance Phone: (213) 346-6817 Peter Lee Executive Director Center for Health Care Rights Phone: (213) 383-4519 Maryland
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
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
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.
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
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.
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
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
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).
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
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