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Consumer Health Plan Appeals

Consumer Health Plan Appeals

Regulations issued by the Departments of Health and Human Services, 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. The rules issued on July 23, 2010 will provide uniformity to the existing patchwork of protections that apply to only some plans in some States, and simplify the system for consumers.

The Affordable Care Act provides consumers with the right to appeal decisions made by their health carrier to an outside, independent decision-maker, no matter what State they live in or what type of health insurance they have. Under the interim final regulations (45 CFR §147.136), plans and issuers must comply with a State 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, which have been outlined in the interim final regulations (45 CFR §147.136), 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. The document is linked by permission from NAIC.

For more information about the regulations, refer to these postings:

HHS will not enforce these rules against issuers of stand-alone retiree-only plans in the private health insurance market.