Understanding Consumers’ Experience with Health Insurance: New California Report on Complaints Provides Insights

Earlier this month, the California Office of the Patient Advocate (OPA) released its first annual report cataloguing complaints and inquiries across four California state health agencies: the Department of Managed Health Care (DMHC), Department of Health Care Services (DHCS), Department of Insurance, and Covered California. Required by state law, the report reviewed the 27,028 consumer complaints that were closed in 2014.

Overall, the agencies received more than 5 million requests for assistance, with the vast majority – over 4.4 million – coming through Covered California, California’s Affordable Care Act (ACA) marketplace. Of the 5 million queries, 27,028 were classified as “complaints,” defined as written or oral grievances, appeals, independent medical reviews, hearings and similar processes to resolve a consumer problem or dispute.

Only 4,366 complaints (16 percent) came through the Covered California service center. Another 1,076 complaints about Covered California came through DMHC, which oversees about 95% of health plans in the state. DMHC received 52 percent of the total complaints, DHCS (the Medi-Cal program administrator) received 17 percent, and the Department of Insurance received 15 percent.

The top 5 complaints comprised 52 percent of all submitted complaints. These were:

  • Denials of claims (18%)
  • Quality of care (11%)
  • Medical necessity denials (10%)
  • Co-pay, deductible, or co-insurance issues (7%)
  • Enrollment or disenrollment issues (6%)

Other complaints related to policy cancellations, eligibility determinations, and coverage. Of the Covered California complaints, 85 percent focused on a denial of eligibility for the marketplace, 13 percent on eligibility determinations, and 2 percent on coverage cancellations.

Data from California consumers attempting to use their coverage complements new data documenting consumers’ enrollment challenges from the Assister Help Resource Center (AHRC) for the federally facilitated marketplaces. It would be useful if more states and federal officials could conduct similar analyses in order to provide a more accurate and complete picture of the consumer experience under the ACA.

Additionally, as the ACA quality ratings and reporting measures go into effect, this report’s inclusion of the health plans with the highest complaint ratios (i.e., those with the largest number of complaints per 10,000 covered lives) has the potential to help consumers further compare plans and make informed coverage choices. While further standardization of data is required, the data collection process also provides an opportunity to improve customer service and act on a regulatory level to address emerging problems either with a particular insurer or system-wide.

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