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Life Health > Health Insurance > Health Insurance

What if a health plan member hates a coverage decision?

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The procedures for handling patient complaints about major medical plan coverage decisions continue to differ from state to state. Officials at the Center for Consumer Information and Insurance Oversight (CCIIO) explain where patients should send requests for outside decision reviews in a new guide aimed at people who help consumers use commercial health insurance coverage.

The Centers for Medicare & Medicaid Services (CMS), a division of the U.S. Department of Health and Human Services (HHS), set up CCIIO to oversee day-to-day implementation of the parts of the Patient Protection and Affordable Care Act of 2010 (PPACA) that affect commercial health insurance.

State regulators, federal regulators and members of Congress began drafting health coverage appeals and external review rules long before President Obama signed PPACA into law.

See also: Jeffords To Offer PARCA Lite Bill

The Obama administration is still using an interim final rule published in 2010 to regulate the appeal and review system, and, up until now, news about the birth of the PPACA public exchange system has mostly overshadowed news about the appeal and review system.

CCIIO officials note in the new guide that insurers themselves handle claims and internal appeals. Outside entities handle external reviews of the insurers’ coverage decisions.

States can handle their own residents’ external reviews if their review systems meet HHS standards. Because of that flexibility, the nature of the entity that handles patients’ requests for external reviews differs from state to state.

All states that have their own state-based exchanges have their own external review systems. Some states with HHS-run exchanges have their own, state-based external review systems. 

Nine states with HHS-run exchanges also have HHS-run external review systems. The states with HHS-run exchanges and HHS-run external review systems are Alabama, Alaska, Florida, Georgia, Louisiana, Montana, Pennsylvania, West Virginia and Wisconsin.

In some of those states, the plan receives the request for an external review and hires an independent review organization (IRO). In others, an HHS-hired independent review contractor gets the requests.

States with state-run review systems may put the health plan, the state insurance department or the state health department in charge of taking requests for reviews.

Patient complaints about a state-run external review process may go either to the state insurance department or the state health department. Patient complaints about an HHS-run external review go to CCIIO.


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