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Complaints

The state Office of the Health Insurance Commissioner (OHIC) only has authority for certain kinds of health insurance plans.  Kindly review the list below to determine whom to contact with your health insurance issue.

Fully-insured, employer-sponsored health insurance
This is generally the only category of insurance over which the OHIC has authority. Approximately 400,000 Rhode Islanders get their insurance through an employer that offers a "fully-insured" health benefit. As such, these benefits are subject to state law and regulation and fall under the authority of the OHIC. To determine if your employer offers a "fully-insured" or "self-insured" benefit (see following section), speak with your employer. If you have a concern about your employer-sponsored, fully-insured coverage, OHIC may be able to assist you.  Please follow the Instructions under Filing a Complaint below.

Self-insured, employer-sponsored health insurance (ERISA-preempted)
If you work for a large company, there is a chance that the employer is "self-insured".  To determine if your employer is self-insured, speak with your employer. Self-insured companies are not subject to state laws and regulations, which are preempted by the Federal Employee Retirement Income Security Act (ERISA).  ERISA preempted employers are subject to regulation by the Federal Department of Labor's Employee Benefits Security Administration. Complaints about a self- funded health plan should be directed to your companies’ human resource department or contact:

U.S. Department of Labor
Boston Regional Office
J.F.K. Building, Room 575
Boston, MA 02203
1.866.444.3272 or 617.565.9600
Fax 617.565.9666
http://www.dol.gov/ebsa/ (external link)

RI STATE EMPLOYEES
The RI DEPARTMENT OF ADMINISTRATION is responsible for oversight of Rhode Island state employee health insurance benefits. If you have concerns regarding state employee or retiree health insurance benefits, please contact:
OFFICE OF EMPLOYEE BENEFITS (External Link- DOA)
401.222.3160
fax 401.222.2964

Out-of State employer-sponsored health insurance
Please contact the Department of Insurance in the state in which your employer is located. The National Association of Health Insurance Commissioners (NAIC) website has links to each state insurance department website.
NAIC state links web page

Medicaid
The Rhode Island Medical Assistance Program, also known as Medicaid, is a federal and state funded program that pays for medical and health related services for eligible Rhode Islanders.

RIte Care is Rhode Island’s Medicaid health insurance program that provides eligible uninsured children, families, and pregnant women with comprehensive health care through one of three participating health plans: Neighborhood Health Plan of RI, United Health Care of New England, and Blue Cross Blue Shield of Rhode Island.

RIte Share is a premium assistance program that helps families get insurance coverage through their employer (or spouse’s employer). If a family qualifies, RIte Share will pay all or part of the employee’s share of the health insurance premium.

Generally, eligibility for RIte Care and RIte Share is based upon income level and family size. Both are administered through the State of Rhode Island Department of Human Services.

For issues regarding RIte Care or RIte Share please contact:
Rhode Island Department of Human Services (DHS)
401.462.5300 (English or Spanish)
Rhode Island DHS RIte Care and RIte Share web page

Medicare
Medicare is the federal health insurance program for almost all Americans age 65 and older and for many adults with permanent disabilities.

For concerns regarding Medicare coverage, please contact:
Centers for Medicare & Medicaid Services - Boston Office
800.633.4227 (General inquiries)
617.565.1232 (Part D inquiries)

or

RI Department of Elderly Affairs
401.462.3000

TRICARE
TRICARE is the United States Department of Defense’s worldwide health care program for active duty and retired uniformed services members and their families. Fact Sheet (external link)
Contact:
877. 874.2273

Federal Employees Health Benefits Program (FEHBP)
Employees of the Federal Government receive benefits through the FEHBP, which is overseen by the U.S. Office of Personnel Management. Current federal employees and their families should contact the employing agency human resources office or the health plan.

Please use the following link to review a list of agency headquarters benefits officers: http://apps.opm.gov/abo/ (external link)

Filing a Complaint

Since many people have the same questions regarding their health insurance, please review our list of frequently asked questions (FAQs) to see if that information answers your question.

If your complaint is related to insurance payment or coverage issue, please be sure to contact your insurance company’s customer/member service department (usually this number can be found on your insurance ID card) to determine what your appeals rights are under your health insurance policy. You will want to be sure you understand your options fully.

Healthcare providers should review and comply with their health plan contracts and administrative policies on appeals before filing a complaint.

If you want to file a complaint with the Office of the Health Insurance Commissioner, please complete the following form and mail to OHIC 1511 Pontiac Ave Building 69 1st Floor, Cranston, RI 02920.

You may email the completed and signed form to healthinsinquiry@ohic.ri.gov

Complaint Form


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