Rules Released On External Appeal Process

Published August 2010

Yesterday, the Obama Administration is announcing both new regulations to empower consumers to appeal decisions made by their health plans or insurance companies and the availability of resources that will be used to help give consumers more control of their health care decisions.  These provisions of the Affordable Care Act will help support and protect consumers and help end some of the worst insurance company abuses.

The new appeals regulations were issued by the Departments of Health and Human Services (HHS), Labor, and the Treasury.  Consumers in new health plans in every State will have the right to appeal decisions, including claims denials and rescissions, made by their health plans.  This includes the right to appeal decisions made by a health plan through the plan’s internal process and, for the first time, the right to appeal decisions made by a health plan to an outside, independent decision-maker, no matter what state a patient lives in or what type of health coverage they have.

In addition, grant applications from the $30 million Consumer Assistance Program are now available to help States and Territories establish consumer assistance offices or strengthen existing ones.  The new funds will be used to provide consumers with the information they need to pick from a range of coverage options that best meets their needs, appeal decisions by plans to deny coverage of needed services, and to select an available primary care provider of their choosing.

“The Affordable Care Act puts patients in control of their healthcare,” said HHS Secretary Kathleen Sebelius.  “Today, if your health plan tells you it won’t cover a treatment your doctor recommends, or it refuses to pay the bill for your child’s last trip to the emergency room, you may not know where to turn.  The Affordable Care Act provisions announced today will provide patients with new important new rights and resources that will help ensure they get the care they need.”

“The appeals rules today will extend important protections and simplify the system for consumers,” said Labor Secretary Hilda Solis. “And they will ensure that consumers in new health plans have access to internal and external appeals processes that are clearly defined, impartial, and designed to ensure that, when health care is needed and covered, consumers get it.”

“The Affordable Care Act provisions we’re announcing today will ensure that consumers have access to a fair, thorough and uniform appeals process if their claim is denied,” said Michael Mundaca, Assistant Treasury Secretary for Tax Policy.  “With these new patient protections, we’re providing consumers with another strong defense against insurance company abuses.”

“The Consumer Assistance Program will support patients both now as we transition to a more competitive, patient-centered health insurance marketplace in 2014 and once that new marketplace is established,” said Jay Angoff, Director of the Office of Consumer Information and Insurance Oversight within HHS.  “These programs can help consumers understand what type of coverage they need, how they can enroll – and then help them if they run into any trouble getting the benefits they’ve paid for.”

For more information about the new appeals regulation or Consumer Assistance Grants program, go to:http://www.healthcare.gov/news/factsheets/protectconsumers_factsheet072210.pdf

Regulation: http://www.dol.gov/federalregister/HtmlDisplay.aspx?DocId=24056&AgencyId=8&DocumentType=2