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The Center for Consumer Information & Insurance Oversight

 

External Appeals

Consumers’ Rights to Appeal Health Plan Decisions

Under the Affordable Care Act, consumers have the right to appeal decisions made by health plans created after March 23, 2010. The law governs how insurance companies handle initial appeals and how consumers can request a reconsideration of a decision to deny payment. If an insurance company upholds its decision to deny payment, the law provides consumers with the right to appeal the decisions to an outside, independent decision-maker, regardless of the type of insurance or state an individual lives in.

Standardizing and Internal and External Appeals Process

Regulations issued by the Departments of Health and Human Services (HHS), Labor, and the Treasury will standardize both an internal process and an external process that patients can use to appeal decisions made by their health plan. These new rules will more closely align the appeals process across all types of plans.

State and Federal External Review Process

Under new Affordable Care Act rules, plans and issuers must comply with the state’s external review process or the federal external review process. State laws that meet or exceed the consumer protections in the National Association of Insurance Commissioners (NAIC) Uniform External Review Model Act will apply to carriers subject to state law.  NAIC promulgated the Uniform Health Carrier External Review Model Act (known as the Uniform External Review Model Act). The NAIC amended this model during the 2010 Spring National Meeting. These amendments were adopted as guidelines under the NAIC’s model laws process.  In addition, until January 1, 2014, a State may operate an external review process under Federal standards similar to the required consumer protections outlined in the July 23, 2010 IFR.

If HHS determines that a State has neither implemented the required consumer protections nor implemented a process that meets the Federal standards that are similar to the required consumer protections, issuers in the State will have the choice of participating in either the HHS-administered external review process or contracting with accredited Independent Review Organizations.  This guidance also phases in the use of multiple Independent Review Organizations for the plans that use them starting next year as a way of ensuring that the external review is unbiased.

HHS is adopting this approach to permit States to operate their external processes under standards established by the Secretary until January 1, 2014 to avoid unnecessary disruption while States work to adopt the consumer protections set forth in the July 2010 regulations.  Starting in 2014, the appeals process will be more closely aligned across all types of plans.

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