Administration Implements Appeals Law

Health plan enrollees have the right to independent, external reviews of adverse coverage determinations, regardless of which state the live in or what kind of insurance they have, based on an interim final rule published July 23rd in the Federal Register. The rule implements provisions of the Patient Protection and Affordable Care Act. It applies to employees in self-insured plans and to fee-for-service medicine as well as managed care. The government estimates that beginning next year, the rule will extend appeals rights to an estimated 31 million Americans enrolled in new employer plans and 10 million Americans in new individual plans. The rule grandfathers existing external appeals procedures in 44 states, provided they meet standards developed by the National Association of Insurance Commissioners. The NAIC standards require clear information on the appeals process for consumers, expedited access to appeals in cases of medical emergency, coverage of costs of appeals by plans, and binding final determinations. States are required to arrange for reviews of appeals by independent entities that are free of conflict-of-interest. IPRO currently performs these independent external appeals in 15 states and the District of Columbia. The rule, which is issued jointly by the Department of Labor, Department of the Treasury and Department of Health and Human Services, is available at