DOI Bruce Rauner Governor Anne Melissa Dowling, Acting Director

Contact The Proper Agency

Where to File Medicare, Medicaid and Other Health Plan Complaints

Updated August 2015

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The Department 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 the Department.

Medicare, Medicare Advantage Plans, Medicare Part D

The U.S. Department of Health and Human Services (Centers for Medicare & Medicaid Services) has jurisdiction over Medicare, Medicare Advantage Plans and Medicare Part D (prescription drugs) claims issues.  Appeal information for these plans is available at http://www.medicare.gov/claims-and-appeals/file-an-appeal/appeals.html  If you have a question or complaint about one of these plans, you may also contact the Senior Health Insurance Program (SHIP) within the Department on Aging at (800) 548-9034 option 2 or (800) 252-8966, option 2 for assistance or email SHIP at http://www.illinois.gov/aging/ship.

Illinois Department of Healthcare and Family Services (HFS) including Medicaid

If you want to file an appeal related to your medical services or items, Developmental Disability (DD), or Elderly Waiver (Community Care Program (CCP)) services, send your request in writing via mail, fax or email to:

Illinois Department of Healthcare and Family Services (HFS)

Attn:  Fair Hearings Section
401 South Clinton, 6th Floor
Chicago, IL 60607
Fax:  (312) 793-2005
Email:  HFS.FairHearings@illinois.gov

Or you may call HFS at (855) 418-4421.  If you use a TTY, call HFS at (877) 734-7429.

Illinois Comprehensive Health Insurance Plan (CHIP)

320 West Washington Street
Suite 700
Springfield, IL  62701-1150
(866) 851-2751 (Illinois only)(217) 782-6333
http://www.chip.state.il.us

Government Employees

  • Federal Employee Benefit Plans (includes postal workers)
    U.S. Office of Personnel Management
    Federal Employees Health Benefits Program
    Room 3443
    1900 E. Street NW
    Washington, DC 20415-1000
    (202) 606-1800
    http://www.opm.gov/
    fehb@opm.gov

  • State of Illinois Employee Quality Care Health Plan, Quality Care Dental Plan, Healthlink Open Access and Coventry Open Access
    Illinois Department of Central Management Services
    Group Insurance Division
    (800) 442-1300
    http://www.illinois.gov/cms/Employees/benefits/
    CMS.WebsiteBenefits@illinois.gov

  • State of Illinois Employee HMO Plans
    Illinois Department of Insurance
    320 W. Washington Street
    Springfield, IL  62767-0001
    (877) 527-9431
    http://insurance.illinois.gov

  • Local Government Health Plans
    This program provides insurance benefits for local government units, such as cities, towns, villages and townships; entities that have the ability to tax or receive monies from the State of Illinois, such as park districts, housing authorities, water districts, schools; and entities allowed by statute, such as rehabilitation facilities, domestic violence shelter and child advocacy centers.
    The Local Care Health Plan, Healthlink Open Access Plan, Coventry Open Access Plan, Local Consumer-Driven Health Plan and Local Care Dental Plan:
    Illinois Department of Central Management Services
    Group Insurance Division
    (800) 442-1300
    http://www.illinois.gov/cms/Employees/benefits/LocalGovernment
    CMS.WebsiteBenefits@illinois.gov

  • Local Government HMO Plans
    Illinois Department of Insurance
    320 W. Washington Street
    Springfield, IL  62767-0001
    (877) 527-9431
    http://insurance.illinois.gov

  • College Insurance Program (CIP)
    This program provides insurance benefits for annuitants receiving a monthly benefit or annuity from the State Universities Retirement System (SURS) who prior to retiring, were an employee of an Illinois community college.
    The College Choice Health Plan (CCHP), Healthlink Open Access Plan, Coventry Open Access Plan, and College Choice Dental Plan:
    Illinois Department of Central Management Services
    Group Insurance Division
    (800) 442-1300
    http://www.illinois.gov/cms/Employees/benefits/LocalGovernment
    CMS.WebsiteBenefits@illinois.gov

  • Teachers’ Retirement Insurance Program (TRIP)
    The Teachers’ Choice Health Plan, Coventry Open Access Plan and Healthlink Open Access Plan
    Illinois Department of Central Management Services
    Group Insurance Division
    (800) 442-1300
    http://www.illinois.gov/cms/Employees/benefits/Teachers
    CMS.WebsiteBenefits@illinois.gov

    Teachers’ Retirement HMO Plans
    Illinois Department of Insurance
    320 W. Washington Street
    Springfield, IL  62767-0001
    (877) 527-9431
    http://insurance.illinois.gov

  • Self-Insured non-federal governmental plans
    The federal Department of Health and Human Services has authority over these plans, which includes state, county, city or municipality self-insured plans.  Check your denial letter or benefit plan for information regarding how to appeal denied claims or services.

  • TRICARE (Champus) for active and retired military personnel and dependents
    Information regarding appeal procedures for the Tricare plans may be found at http://www.tricare.mil/Resources/Appeals.aspx.

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

Many large employers provide health benefits for their employees through self-insured plans.  Although self-insured plans are frequently administered by an insurance company, it is the employer and not the insurance company that bears the risk for paying claims.  Generally, federal law exempts self-insured employer plans from state insurance regulation.  The same is true of health & welfare benefit plans (union plans).  In most cases, the Department of Insurance will accept your complaint, inquiry or request for assistance and forward it to the plan in an effort to facilitate.  We recommend you refer to your member handbook on how to file an appeal under the plan.  The U.S. Department of Labor has some oversight of these plans.

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

Southern Illinois:
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
www.dol.gov/ebsa

Self-Insured Church Plans

The federal Department of Treasury, Internal Revenue Service has authority over these plans.  However, they follow the US Department of Labor rules for external review.  Check you benefit plan for information regarding how to appeal denied claims or services.  You may also wish to contact the US Department of Labor.

Policies Purchased in Another State

Complaints should be sent to the Department of Insurance in the state where you purchased the policy.  You many find contact information for those agencies at http://www.naic.org/state_web_map.htm.  The information should also be included on your denial letter or within your member handbook.  For HMO coverage, please contact the Illinois Department of Insurance.

Worker’s Compensation

The Department of Insurance generally does not have the authority to investigate complaints regarding Worker’s Compensation claims, including complaints about fee schedules.  Inquiries and complaint should be directed to:

Written questions or complaints:

Illinois Workers' Compensation Commission
James R. Thompson Center
100 W. Randolph, Suite 8-200
Chicago, IL 60601-3275

Phone inquiries:

(312) 814-6611 Chicago Area
(309) 671-3019 Peoria Area
(815) 987-7292 Rockford Area
(217) 785-7087 Springfield Area and Southern Illinois
(866) 352-3033 Statewide

For More Information

Call our Office of Consumer Health Insurance at (877) 527-9431
or visit us on our website at http://insurance.illinois.gov