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HIX Final Rule Details Payment, Appeals Standards

Cheryl Clark, for HealthLeaders Media, August 29, 2013

The 300-page rule also affords numerous ways consumers may make payments on their monthly exchange premiums, and requires qualified health plans that issue exchange products "to accept a variety of payment methods" and let purchasers know in advance what options are offered "so they may utilize their preferred payment method."

Among the most complex parts of the document, the final rule sets forth standards for agent and broker participation in what are called federally facilitated and state facilitated marketplaces.

The rule also establishes processes for appealing eligibility denials, resolutions and due process and procedural rights of the appellant. This includes an informal resolution. If the consumer is dissatisfied with that decision, a more formal hearing could ensue.

State-based marketplaces have flexibility to implement their own appeals process in accordance with the final rule, although appellants in the individual market "retain the right to escalate their appeal to the federal appeal process managed by HHS if they remain dissatisfied" by the state-based appeals process.

The rule sets forth a separate appeals process for employers whose coverage plans do not provide "minimum essential coverage" meeting the rule's standards.


Cheryl Clark is senior quality editor and California correspondent for HealthLeaders Media. She is a member of the Association of Health Care Journalists.
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