State Agencies regulating HMOs and PPOs

Who regulates health insurance?

Health insurance obtained by the individual or through an employer or trade group (group policy) is regulated in the United States by the state governments, not by the federal government. If you already tried unsuccessfully to resolve your dispute with your insurer, whether it is a health maintenance organization (HMO) and preferred provider organization (PPO), you can seek help from the appropriate state agency. Most states have one department or agency to regulate all health insurance plans in their state, but some states differentiate between HMOs and PPOs. Find your state in the table below to find the appropriate agency and its website. Please note: If you have Medicare or a self-funded employer plan, this information does not apply to you. Those plans are regulated by other agencies, and complaints dealing with those plans cannot be handled by the agencies listed below.

Which state should you contact?

Contact the state you were living in when you applied for your policy. If you moved since then but still have the same policy, such as if you relocated temporarily for work or are attending school out-of-state, make sure to contact the state you were living in before you moved. The departments and their respective duties may have changed since this chart was compiled. Verify that the agency listed for your state regulates your particular plan before filing a complaint, and after you file the complaint, follow-up to make sure they have all the necessary information to proceed


The information presented in this publication is for general informational purposes and is not a substitute for legal advice. If you have a specific legal issue or problem, United Policyholders recommends that you consult with an attorney. Guidance on hiring professional help can be found in the “Find Help” section of www.uphelp.org. United Policyholders does not sell insurance or certify, endorse or warrant any of the insurance products, vendors, or professionals identified on our website.

Source: https://uphelp.org/claim-guidance-publications/state-agencies-regulating-hmos-and-ppos/
Date: June 20, 2021