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White House Unveils Consumer Rules to Appeal Health Plan Decisions

Janice Simmons, for HealthLeaders Media, July 23, 2010

The Obama Administration announced on Thursday new regulations that would permit consumers to appeal decisions—such as claims denials and rescissions—made by their health plans or insurance companies.

The new regulations—issued by the Departments of Health and Human Services (HHS), Labor, and Treasury—include the right for consumers to appeal decisions made by a health plan through the plan’s internal process or through an outside, independent decision-maker. This will apply to any state where a patient lives or whatever type of health coverage the consumer has.

Grant applications from the $30 million Consumer Assistance Program will be 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 select from a range of coverage options that meet their needs. It also will be used to appeal decisions by plans to deny coverage of needed services, or to select an available primary care provider of their choosing.

"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," said HHS Secretary Kathleen Sebelius in a statement. The new healthcare reform act provisions "will provide patients with new rights and resources that will help ensure they get the care they need."

The internal appeals process will guarantee a venue where consumers can present information to their health plan providers.

Under the new rules, new health plans beginning on or after Sept. 23, 2010, must have an internal appeals process that:

  • Allows consumers to appeal when a health plan denies a claim for a covered service or rescinds coverage;
  • Gives consumers detailed information about the grounds for the denial of claims or coverage;
  • Requires plans to notify consumers about their right to appeal and instructs them on how to begin the appeals process;
  • Ensures a full and fair review of the denial; and provides consumers with an expedited appeals process in urgent cases.

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