Three federal agencies have combined to announce new regulations that would allow patients to appeal health plan denials and "help support and protect consumers and help end some of the worst insurance company abuses."
The regulations, issued Thursday by the Departments of Health and Human Services, Labor and Treasury, are part of new patient consumer rights mandated under the Affordable Care Act. They give patients the right to appeal decisions made by a health plan through the plan's internal process and, for the first time, the right to appeal decisions made by a health plan to an outside, independent decision-maker, no matter what state a patient lives in or what type of health coverage he or she has.
Insurance companies say they already offer a review process. According to Robert Zirkelbach, press secretary for America's Health Insurance Plans, "Health plans have a long track record of supporting third-party review to give patients greater peace of mind about their health care coverage."
"We support the National Association of Insurance Commissioners external review model," Zirkelbach said, "and we are currently reviewing the new regulations to see how they compare to existing state programs."
In addition to the new regulations issued Thursday, the administration announced $30 million in grants from the Consumer Assistance Program to help states and territories establish consumer assistance offices or strengthen existing ones.
According to HHS Secretary Kathleen Sebelius, the new funds will be used to provide consumers with the information they need to pick from a range of coverage options that best meets their needs, appeal decisions by plans to deny coverage of needed services, and select an available primary care provider of their choosing.
"The Affordable Care Act puts patients in control of their healthcare," Sebelius said.
"Today, 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," she said. "The Affordable Care Act provisions announced today will provide patients with new important new rights and resources that will help ensure they get the care they need."According to Jay Angoff, director of the HHS Office of Consumer Information and Insurance Oversight, the Consumer Assistance Program will support patients both now as the country transitions to a more competitive, patient-centered health insurance marketplace in 2014 – and once that new marketplace is established.
"These programs can help consumers understand what type of coverage they need, how they can enroll – and then help them if they run into any trouble getting the benefits they've paid for," Angoff said.