The Affordable Care Act establishes common-sense consumer protections and creates a more transparent marketplace. Fair rules and transparency help create a more level playing field between consumers and insurers. The law also empowers States by putting them in the driver’s seat in implementing many of these new consumer protections.
On July 23, 2010, the Departments of Health and Human Services, Labor, and the Treasury published an interim final rule regarding standards for internal claims and appeals and external review processes for group health insurance plans and health insurance issuers offering coverage in the group and individual markets. This rule works to give people in most plans better information about what their rights are and why their claims were denied or coverage rescinded or taken away. Under the rule, consumers have the:
These protections and standards are an important step forward in reforming the health care system to make sure it works for consumers, not just insurance companies.
State Flexibility and Transition to 2014
Through guidance and regulations issued in July 2010 and July 2011 the Departments have given States a number of options to implement the strong consumer protections included in the external review process.
This approach maintains the unprecedented consumer protections provided in the Affordable Care Act while reflecting comments from stakeholders and giving States the flexibility they need to implement the law. This approach also permits States to operate their external review processes and avoids unnecessary disruption while States work to adopt the consumer protections set forth in the July 2010 regulations.
The list below indicates which of the three options described above applies to the external appeals review process in each State. If a State changes its external review process in the future, the State may contact CCIIO to request a new determination.
Updated November 1, 2013
|Meets Paralell||Meets Similar||HHS Administered Process/Independent Review Organization Process|
|Colorado||District of Columbia||Florida|
|New Jersey||Northern Mariana Islands|
|New York||Puerto Rico|
|North Carolina||Virgin Islands|
 Beginning January 1, 2014, for all claims submitted on or after January 1, 2014.
 Beginning January 1, 2016.