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Consumers Union pans health plan complaint process

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A health policy specialist says state insurance regulators should think about updating their health plan complaint programs.

Betsy Imholz, a San Francisco-based special projects director at Consumers Union, is preparing to give a presentation on the topic Sunday, in San Diego, at the summer meeting of the National Association of Insurance Commissioners.

Imholz will be delivering the presentation together with Elizabeth Abbott, director of California’s Office of the Patient Advocate, at a session organized by NAIC’s consumer liaison committee.

The same session will feature presentations on bills for air ambulance services and the U.S. Department of Labor’s new fiduciary rule

One of the original goals of the creators of the Patient Protection and Affordable Care Act of 2010, and of many earlier health system change efforts, was to help consumers appeal health plan claim denials.

Related: What if a health plan member hates a coverage decision?

But, in 2015, when Consumers Union surveyed consumers about experiences with “surprise medical bills,” the group found that 87 percent of privately insured U.S. adults did not know what government agency handles health coverage complaints, Imholz and Abbott say in their presentation slidedeck.

Seventy-three percent of the consumers surveyed did not know whether they had a right to appeal a claim denial to the state or to an independent expert, Imholz and Abbott say.

The speakers have also included 2014 complaint data for health insurance plans and managed care plans.

In 2014, California regulators received 4,079 consumer complaints for the health insurance plans and 13,994 complaints for the managed care plains. 

For the top 10 issuers, the number of complaints per 10,000 enrollees ranged from 0.04 to 47.64 for plans sold by issuers licensed as insurance companies, and from 2.54 to 12.28 for plans sold by issuers licensed as managed care companies. 

Only two managed care companies attracted more than 10 complaints per 10,000 enrollees, but four insurers had complaint ratios over 10 per 10,000 enrollees.

NAIC is a Kansas City, Missouri-based trade group for state insurance regulators.

NAIC pays the travel bills for some consumer group and patient group representatives who speak for consumers in NAIC proceedings. NAIC classifies those people as funded consumer representatives. Would-be consumer representatives who have their own travel funding can serve on its consumer liaison committee as unfunded representatives. Imholz and Abbott are both unfunded consumer representatives. 

Here are some other highlights from the consumer liaison session packet:

  • In part because federal law prohibits state efforts to regulate air transportation rates, some consumers who use air ambulance services in emergencies are facing out-of-network air ambulance bills. Consumers Union has seen at least one bill for more than $50,000. The group wants states to educate members of the public about air ambulance costs, hold hearings on that issue and encourage the federal government to let states regulate air ambulance costs.

  • Several consumer groups joined together to ask state insurance regulators to set tougher minimum standards for health plans’ covered drug lists. The groups want states to keep issuers from putting all drugs of a given type in a category with very high out-of-pocket costs, or from making it harder for enrollees to use certain drugs in the middle of a plan year.


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