Contact The Proper Agency - Where to File Medicare, Medicaid and Other Health Plan Complaints

Revised May 2007

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The Division of Insurance handles thousands of health insurance and HMO inquiries and complaints every year. However, not all health plans fall under our jurisdiction. This fact sheet provides information regarding plans that are not regulated by our Division.

Medicare

The U.S. Department of Health and Human Services (Centers for Medicare & Medicaid Services) has jurisdiction over Medicare claims issues. However, if you have a question or complaint about a Medicare claim or the Medicare appeal process, you may contact our Senior Health Insurance Program (SHIP) at (800) 548-9034 for assistance.

Medicare Managed Care Plans

If your complaint involves one of the following Medicare Health Maintenance Organizations, Medicare Fee-For-Service plans or Medicare Preferred Provider Organization plans, you should send your complaint directly to the Centers for Medicare & Medicaid Services (CMS), the federal agency that administers those contracts.

 

KidCare
Illinois Department of Healthcare and Family Services
State of Illinois -- KidCare Unit
PO Box 19122
Springfield, IL 62794-9122
(866) 468-7543
http://www.allkidscovered.com

Illinois Comprehensive Health Insurance Plan (CHIP)
320 West Washington Street
Suite 700
Springfield, IL 62701-1150
(866) 851-2751
http://www.chip.state.il.us

Government Employees

• Federal Employee Benefit Plans (includes postal workers)
  U.S. Office of Personnel Management
  Agency Employee Review
  Retirement and Insurance Group
  1900 E. Street NW
  Washington, DC 20415-1000
  (202) 606-0777

• State of Illinois Employee Quality Care Health Plan, Life Insurance and Dental Insurance
  Department of Central Management Services
  Bureau of Benefits
  201 East Madison
  Springfield, IL 62702
  (800) 442-1300
  http://www.cms.il.gov/cms/2_servicese_ben/groupins.htm

• State of Illinois Employee HMO Plans
  Division of Insurance
  320 W. Washington Street
  Springfield, IL 62767-0001
  (877) 527-9431

• Illinois Retired Teachers Plan or Local Government Quality Care Health Plan
  Department of Central Management Services
  Bureau of Benefits
  201 East Madison
  Springfield, IL 62702
  (800) 442-1300
  http://www.cms.il.gov/cms/3_servicese_ben_choice/choice_triphome06.htm

• TRICARE (Champus) for active and retired military personnel and dependents
  
  For Claim Denials:
  
  Health Net Federal Services, Inc.
  c/o PGBA, LLC/TRICARE Claim Appeals
  P.O. Box 870148
  Surfside Beach, SC 29587-9748
  
  For Prior Authorization Denials:
  
  Health Net Federal Services, Inc.
  c/o PGBA, LLC/TRICARE
  Authorization Appeals
  P.O. Box 870142
  Surfside Beach, SC 29587-9742
  
  (877) 874-2273
  http://www.tricare.mil

Self-Insured Employee Benefit Plans/Union Plans or Health & Welfare Plans

Individual employers and certain employee organizations may self-insure their employee health benefit plans under the authority of the Employee Retirement Income Security Act (ERISA), a federal law. ERISA preempts state regulation of the self-insured plans. We encourage you to refer to your member handbook for the proper appeal procedures. The Division of Insurance accepts complaints involving self-insured employee benefit plans; however, we are not always able to obtain an answer and we have no authority to intervene or require the plan to take an action. The U.S. Department of Labor has some oversight of these plans.

In addition, union plans (health & welfare plans) are preempted from state regulation by federal law. You should refer to your member handbook for the proper appeal procedures. Once again, the U.S. Department of Labor has some oversight of these plans.

The U.S. Department of Labor Chicago Regional Office serves the following counties:

U.S. Department of Labor
Employee Benefits Security Administration
Chicago Regional Office
200 W. Adams Street, Suite 1600
Chicago, IL 60606
(866) 444-3272 or www.dol.gov/ebsa

Residents of all other counties in Illinois should contact:

U.S. Department of Labor
Employee Benefits Security Administration
Kansas City Regional Office
1100 Main Street, Suite 1200
Kansas City, MO 64105
(866) 444-3272 or www.dol.gov/ebsa

Policies Purchased in Another State

Complaints should be sent to the Division of Insurance in the state where you purchased the policy. Check your insurance booklet or policy for the address or call us for that information. For HMOs, please contact the Division of Insurance for assistance.

Workers' Compensation

For More Information

Call our Consumer Services Section at (312) 814-2427 or
our Office of Consumer Health Insurance toll free at (877) 527-9431
or visit us on our website at Division of Insurance