Health Care Reform Update

On August 1, 2011, HHS completed and released their external appeals determinations for states, as part of the process to implement new protections under the Patient Protection and Affordable Care Act.

As you may remember, on July 23, 2010, HHS 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give people in most plans better information about what their rights are and why their claims were denied or coverage rescinded or taken away. When the interim rule was released last year, BIAA submitted comments to HHS that can be found here.

According to what HHS released on 8.1.11, under the determination process, a state:

  • May meet the "strict standards" included in the July 2010 rules, which set forth 16 minimum consumer protections based on the Uniform Health Carrier External Review Model Act written by the National Association of Insurance Commissioners (NAIC)*;
  • May operate an external review process under similar standards to those outlined in the July 2010 interim final rule.  These similar standards apply until January 1, 2014. or;
  • May have neither implemented the strict standards nor the similar standards. In this case, issuers offering non-grandfathered plans and policies in the State will choose an HHS-administered process or contract with accredited independent review organizations to review external appeals on their behalf.

Please see the official document for more information and for a chart of where states fall in the process. 18 states will need to choose an HHS-administered process or contract with accredited independent review organizations. States can request reconsideration - final determinations will be made by October 1 for those states.

BIAA will continue to closely monitor PPACA regulations as they are released by HHS and alert grassroots advocates if any action is needed.

* Susan Connors, president and CEO of the Brain Injury Association of America (BIAA), was appointed by the National Association of Insurance Commissioners (NAIC) as a consumer liaison representative for 2011. In this capacity, Ms. Connors represents the needs of individuals with brain injury to state insurance commissioners at three onsite meetings and collaborate with representatives from similar organizations, such as American Heart Association, MS Society and Consumers Union, on federal advocacy issues.


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