How to escalate to your state insurance department

Every state has an insurance department (sometimes called the Department of Financial Regulation or a similar name). It regulates fully-insured commercial and individual plans. The DOI has real leverage: it licenses the insurer to sell in the state. A DOI complaint often prompts a fast, careful response from the plan.

When to file

• The plan is stonewalling (missed deadlines, will not answer)
• The plan denied without a rational reason
• The plan is refusing to comply with an external review reversal
• The plan is treating your appeal in bad faith (repeated lost files, contradictory statements)

When not to file

• The appeal has not been through internal appeal yet
• You just do not like the plan's decision but the decision was reasoned
• Your plan is a self-funded ERISA plan (state DOI has limited jurisdiction; see How to escalate to your employer)

Which plans the state DOI can help with

• Fully-insured group health plans (small and large employer)
• Individual and family plans (marketplace and off-exchange)
• Medicare Supplement (Medigap)
• State-regulated dental and vision

Not:

• Self-funded ERISA plans (federal jurisdiction, primarily)
• Medicare Advantage (federal, though state DOI can sometimes forward)
• Medicaid managed care (state Medicaid office primarily)

If you are unsure which category your plan falls into, ask your HR benefits person for a "yes or no" on self-funded, or check the ERISA-plan indicator on your Summary Plan Description.

How to file

1. Find your state DOI website. Search "[your state] insurance department consumer complaint"
2. Almost every state has an online consumer complaint form
3. Some states allow paper filings (mailing address on the site)
4. On the $199 tier, your PDF includes a companion sheet with the mailing address for your state DOI

What to include

• A short narrative (one page or less) of what happened
• The insurer name and plan year
• Your member ID
• Copies of the denial letter, your appeal, the plan's response (or lack of one), and your certified-mail proof
• The specific plan provisions you believe the insurer violated
• What outcome you want (payment of the claim, reprocessing, a written decision, an apology, and so on)

What to expect

• Acknowledgment within a week or two
• The DOI will forward your complaint to the insurer
• The insurer must respond in writing, usually within 30 days
• The DOI reviews the response and either closes the complaint or presses further
• The DOI does not usually order the insurer to pay a specific claim, but the response often includes reprocessing

What the DOI does not do

• Represent you as counsel
• Guarantee a specific outcome
• Take over the appeal on your behalf

While the DOI complaint is pending

• Continue any external review or second-level appeal on the parallel track
• Do not withdraw the DOI complaint just because the insurer starts being polite
• Save every response

Federal parallels

• ERISA plans: file with the US Department of Labor Employee Benefits Security Administration (EBSA). Call 1-866-444-3272 or file online at askebsa.dol.gov
• Medicare Advantage: complain to CMS through 1-800-MEDICARE
• Medicaid managed care: complain to your state Medicaid office (usually the Department of Health and Human Services)

Follow up

If you do not get an acknowledgment within two weeks, follow up. State DOI offices are usually understaffed but they respond to nudges.