How to File a Complaint About Your Health Insurance
This guide will provide some basic information about filing complaints to enforce your health insurance rights. If you or someone you know has questions about how health insurance works for mental health or substance use disorder call our free helpline at 888-614-5400.
What Is a Complaint?
If you received a denial letter from your insurance plan and want to challenge that decision, the correct process would be to file an appeal. The denial letter will contain information about your appeal rights, the process, and deadlines for filing. CHAMP can also help you with an appeal. An appeal is different than a complaint.
Complaints notify the government agency that regulates the insurance company that it may have violated your rights or the law.
Complaints can be written and filed by anyone. You do not need a lawyer, and there is no fee for filing one.
Why Should I File a Complaint?
Filing a complaint opens an investigation to figure out whether the plan has violated your rights or the law.
The more complaints that are filed against a health insurer the easier it is for the government to hold them accountable.
A complaint may also help resolve your individual issue.
Where Do I File a Complaint?
Where you file a complaint depends on the type of health insurance you have.
In New York, insurance I.D. cards are supposed to make clear what type of insurance policy you have. If you are unsure what type you have you can call the CHAMP helpline for help finding out.
- Employer Self-Funded
Complaints about self-funded plans are filed with the U.S. Department of Labor. You can file over the phone by calling 1-866-444-3272, by mail, or online at www.askebsa.dol.gov/WebIntake/
- Employer Fully-Funded
Complaints about fully-funded plans and other state-regulated commercial plans, are filed by mail or online with New York State’s Department of Financial Services at www.dfs.ny.gov/complaint
- Fee for Service Medicaid
Complaints about Medicaid are handled by New York State’s Department of Health: Fee for Service (FFS) Medicaid complaints can be sent to FFSMedicaidPolicy@health.ny.gov
- Managed Medicaid
Medicaid Managed Care and Health and Recovery Plan (HARP) complaints can be filed by calling 518-486-1429 or 800-206-8125 or by emailing: NYSDOH.BCS.Behavioral.Health.Complaints@health.ny.gov
Medicaid Managed Long-Term Care complaints can be filed at 866-712-7197 or by emailing: mltctac@health.ny.gov
- Child Health Plus (CHIP)
If you, or your child, has Child Health Plus, you can complain to the New York State Department of Health by calling 800-698-4543or by emailing: CHPlus@health.ny.gov
- Essential Plan
If you have coverage through an Essential Plan from the New York State of Health Exchange, you can complain to the New York State Department of Health by emailing: Essentialplancomplaints@health.ny.gov
- Medicare
Complaints about all Medicare insurance plans, including Original Medicare, Medicare Advantage, Medigaps, and Part D prescription drug plans, are filed with the Center for Medicaid and Medicare Services by calling 1-800-MEDICARE.
Not Sure what type of insurance you have?
Need help writing the complaint?
CHAMP can help you with both, just give us a call.
What Do I Need for a Complaint?
There is no set form used by all agencies so there are some small differences in what you will be asked for in your complaint depending on where you are filing. However, there are some things that every agency asks, and you should be ready to provide in your complaint.
- Your contact information: The agency you complain to will ask for your name, phone number and address. They might also ask you to confirm your date of birth. If you are listed as a dependent (like a spouse, domestic partner, or child), they may ask for the contact information of the policy holder too.
- Your health insurance information: The company or plan name, the state it is from, and your policy number. This information can be found on your health insurance card.
- Your reason for filing a complaint: You should prepare a short explanation of what your health insurance plan did wrong and how you were affected by their actions.
- Your supporting documents:
Have copies of:
- Any insurance cards
- The plan’s denial letters
- Explanations of benefits
- Bills or other documents from your provider
- Any other communications you have received from your insurance
You can also describe any calls you have made to your plan. If you have the names of plan representatives you spoke to and reference numbers for the calls, it helps to include those as well.
What Happens After I File a Complaint?
When you file a complaint, an investigation will be opened.
After reading through the information you provided, the agency will send a letter to the insurance company asking for a response and any additional documents they may have about your case. Sometimes the agency may also reach out to you for more information.
If the agency finds the insurance plan violated the law or your rights, they may ask the plan to pay a fine and require them to change their processes.
Sometimes the agency will not find enough evidence to prove a violation of the law or your rights.
The agency may only have enough evidence to show that what happened was a one-time mistake.
In either situation, the plan may agree to correct the issue.
This is why it is important for people to file complaints. The more complaints that are filed against a health insurance plan the harder it is for them to say it was a one-time error.