Understanding the Role of Insurance Commissioners in Health Care
While payers like traditional Medicare and Medicaid are managed by federal and state governments, private insurance companies are managed independently. To ensure private insurers maintain compliance with applicable laws and regulations, state governments have departments of insurance. They work to protect consumers and health care providers in their state.
On this page:
- What Is an Insurance Commissioner?
- What Insurance Commissioners Can and Cannot Do
- When and How to Contact an Insurance Commissioner
- Resources and Templates
What Is an Insurance Commissioner?
An insurance commissioner is a state-appointed or elected official who oversees the insurance industry within their state. Each state has different laws and regulations that dictate how insurers operate and define the scope of the state insurance commissioner. Though this varies from state to state, insurance commissioners and their departments are generally authorized to:
- License insurance companies and agents
- Investigate consumer and provider complaints about insurance practices
- Enforce laws and regulations that apply to private insurers
- Educate consumers about their rights and insurance options
- Monitor insurance company solvency to protect policyholders.
What Insurance Commissioners Can and Cannot Do
They can investigate complaints about private insurance companies failing to follow laws or denying coverage improperly.
They cannot interfere with private contracts between insurance companies and providers or consumers unless there is a direct violation of a law that can be enforced by the insurance commissioner.
They cannot intervene with federal- or state-directed programs like Medicare or Medicaid and will not engage directly with those programs. Complaints about those programs should be made directly to the Medicare Ombudsman or the local state Medicaid department.
They can sometimes intervene when private insurance companies managing Medicare Advantage or Medicaid managed care plans violate laws and regulations. This will depend on state law, waivers, and the type of violation. Some insurance commissioners are seeking authorization to provide additional oversight of these plans.
If you are unsure whether your state insurance commissioner can help, check directly with your local insurance commissioner’s office.
When and How to Contact an Insurance Commissioner
Any reimbursement or authorization challenges should always be addressed with the insurance plan first. However, there may be times when problems cannot be resolved through direct communication or appeals with the insurer. Your state insurance commissioner will have a specific scope, but they can generally help if:
- A health plan is systematically denying coverage for medically necessary services or violating a patient’s policy terms
- You're repeatedly receiving inconsistent or unclear policy guidance from a payer
- There are repeated delays or nonpayment of clean claims
- An insurer is improperly credentialing or terminating provider agreements
- You suspect a violation of state or federal law
- Example: The payer does not respect state-mandated coverage laws (e.g., autism coverage, telepractice parity) that apply to the patient’s plan.
- Example: The payer is misinterpreting the Mental Health Parity and Addiction Equity Act and inappropriately denying or processing claims.
Tip: Some insurance commissioner departments have a provider-specific complaint process separate from consumer portals. However, direct consumer or patient complaints are typically reviewed more quickly.
Identify Your Commissioner and Complaint Process
See the National Association of Insurance Commissioners' (NAIC) find by state resource.
Submitting a Complaint
In order to determine whether they can get involved and to fully investigate the complaint, the commissioner’s office needs sufficient information from you and/or the consumer. Providing everything upfront will also speed up the investigation process. Here are some of the items that should be included with a complaint (when applicable):
- Provider contact information and NPI
- Patient's insurance plan and policy number
- A signed release from the provider indicating the patient is allowing them to submit a complaint on their behalf
- A written summary of the issue, including dates and contacts
- Denials, explanations of benefits, or nonpayment documentation
- Any appeal outcomes or insurer responses
- Reference to applicable state or federal laws, if known
- Description of what you’re seeking (e.g., coverage approval, billing correction)
Visit your state’s insurance department website or the NAIC Resource Directory to locate complaint submission portals.
