The lead role is usually taken by state insurance regulatory agencies, with the contribution of state health agencies declining in several states in recent years. There is also a wide spectrum in the type of consumer assistance or ombudsman programs available to people with health insurance complaints. The Office of the Health Care Ombudsman in Vermont is the most independent public sector model across the studied states, having its own statutory basis including legislative protection for undertaking consumer advocacy and dedicated funding through a contract, with the authorizing legislation specifying that the contract be awarded to a non-profit organization. According to an NAIC survey, only 26 states affirmatively publish complaints information. While there are some examples of best practice in complaints report cards, many reports are overly complex and provide insufficient guidance to consumers, suggesting that currently they are of most value to regulators in top-down accountability.
Grievances are internal complaints received directly by health insurance plans.
In four states health insurance plans are required to regularly report grievance data to insurance regulatory agencies, with five states specifying the format for collection of grievance data. However there is no consistency in grievance data collection requirements across the states. Publication of grievance data is limited, with only New York publishing grievance data in its annual consumer guide, while Oregon makes grievance data available on its web site. There is a hierarchy of complaints handling, with state regulators seeing only the tip of the iceberg in consumer complaints. Across three states for which data were available, the volume of grievances received directly by plans was about seven to eight times greater than the volume of complaints received by state insurance regulatory agencies.