Long before Congress sent the Patient Protection and Affordable Care Act (PPACA) bill to President Obama in 2010, Congress was working on controversial bills to establish a “patients’ bill of rights.”
Most of the work focused on efforts to establish minimum standards for internal reviews, and external appeals, for patients who wanted to object to managed care plan benefits decisions.
In 1998, for example, National Underwriter Life & Health, one of the publications that backs LifeHealthPro.com, covered a doomed attempt by Sen. James Jeffords, R-Vt., to organize support for a bill that would set up national standards for appeals.
PPACA included a section establishing the long-sought standards for appeals, but the U.S. Department of Health and Human Services (HHS) has been using interim final regulations issued in 2010 to implement the provisions, and its Center for Consumer Information & Insurance Oversight (CCIIO) PPACA implementation division has not made significant changes to the external appeals section of its website in more than a year.
CCIIO, HHS, and the Centers for Medicare & Medicaid Services — the HHS agency in charge of CCIIO — seem to have published little information about state or federal health plan decision appeals efforts elsewhere.
But CMS has let some of the appeal and review data it has quietly been collecting over the years surface in a routine paperwork review packet. CMS sent the packet to the federal Office of Management and Budget (OMB) to get permission to continue collecting the information needed to implement the PPACA appeals and review standards.
For a peek at some of the information in the packet, read on.
1. The CMS grievance process data is a good source of data on PPACA grandfathering.
To analyze trends in the number of claims, officials need to have numbers for the number of the non-grandfathered health plan enrollees who are subject to the PPACA grievance requirements and the number of grandfathered plan enrollees who are not subject to the requirements.
In the paperwork review packet, CMS gives numbers for the individual market and the government group plan market.
In the individual market, the percentage of enrollees who still had grandfathered coverage dropped to 22 percent in 2013, from 40 percent in 2011.
In the government group plan market, the percentage in grandfathered plans dropped to 56 percent, from 82 percent.