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 standardize both an internal process and an external process that patients can use to appeal decisions made by their health plan. These rules 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, 2018, 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.
HHS is adopting this approach to permit States to operate their external processes under standards established by the Secretary until January 1, 2018 to avoid unnecessary disruption while States work to adopt the consumer protections set forth in the July 2010 regulations. Starting in 2018, the appeals process will be more closely aligned across all types of plans.
- March 5, 2020 Information Related to COVID–19 Individual and Small Group Market Insurance Coverage
- March 12, 2020 FAQs on Essential Health Benefits Coverage and the Coronavirus (COVID-19)
- March 18, 2020 FAQs on Catastrophic Plan Coverage and the Coronavirus Disease 2019 (COVID-19)
- March 24, 2020 FAQs on Availability and Usage of Telehealth Services through Private Health Insurance Coverage in Response to Coronavirus Disease 2019 (COVID-19)
- March 24, 2020 Payment and Grace Period Flexibilities Associated with the COVID-19 National Emergency
- March 24, 2020 FAQs on Prescription Drugs and the Coronavirus Disease 2019 (COVID-19) for Issuers Offering Health Insurance Coverage in the Individual and Small Group Markets
- April 11, 2020 FAQs about Families First Coronavirus Response Act and the Coronavirus Aid, Relief, and Economic Security Act Implementation
*This document was updated on April 15, 2020, to correct an error in footnote 10 regarding the current end date of the public health emergency related to COVID 19.
- April 13, 2020 Postponement of 2019 Benefit Year HHS-operated Risk Adjustment Data Validation (HHS-RADV)