Reform Alert - News from the Blues' Office of National Health Reform

Proposed rule establishes HHS complaint system

July 8, 2013

The Program Integrity proposed rule issued June 14 establishes a new requirement for resolving complaints forwarded to a Qualified Health Plan (QHP) issuer by the Department of Health and Human Services (HHS) operating in a Federally-facilitated Marketplace (FFE), such as Michigan.

CMS acknowledges that states currently play a key role in handling various types of consumer complaints1, and anticipates that many cases will be presented first to the state department of insurance and handled according to state laws and regulations. CMS also recognizes many complaints will be brought to the QHP issuer by the complainant directly, and will be processed according to the issuer’s internal customer service system.

But with respect to complaints related to Federally-facilitated Marketplace-specific topics brought to HHS and forwarded to the QHP issuer, the proposed rule provides that the complaint must be addressed and resolved by the issuer according to certain standards, including:

  • Use of an HHS complaint tracking system
  • Timeliness standards for resolving a complaint
    • 15 days for a standard complaint
    • 72 hours for an urgent complaint

Timeliness standards (seven days) for notifying complainants of resolution

Complaints may be input into the HHS complaint tracking system by a “variety of individuals”, including HHS staff, Navigators and other assistors and Consumer Assistance Programs. The types of complaints that will be handled through the HHS complaint tracking system may range from concerns about a QHP’s call center wait times to the demeanor of QHP customer service personnel.

CMS will use data to identify trends, areas of concern and compliance issues.

CMS advised that if a complaint not related to FFE-specific topics is brought to HHS rather than the state, CMS will work with the state to ensure that such cases are addressed by the state in accordance with its own laws, regulations and processes.

Where can I find more information?

More information can be found in 45 CFR 156, Subpart K (PDF).


1 The proposed rule refers to complaints as “cases”, and defines a “case” as a communication brought by a complainant that expresses dissatisfaction with a specific person or entity subject to state or federal laws regulating insurance.


The information in this document is based on preliminary review of the national health care reform legislation and is not intended to impart legal advice. The federal government continues to issue guidance on how the provisions of national health reform should be interpreted and applied. The impact of these reforms on individual situations may vary. This overview is intended as an educational tool only and does not replace a more rigorous review of the law’s applicability to individual circumstances and attendant legal counsel and should not be relied upon as legal or compliance advice. As required by US Treasury Regulations, we also inform you that any tax information contained in this communication is not intended to be used and cannot be used by any taxpayer to avoid penalties under the Internal Revenue Code.