Cheryl Fish-ParchamFamilies USA

January 28, 2010

Claim denied – not “medically necessary” Claim denied – benefit not covered Claim denied – pre-existing condition Insurer won’t sell due to pre-existing

condition Insurance cancelled Charged too much Subsidy problem

Some states provide for internal and external review for claims denials in some plans; NAIC has developed a model law for states. These are usually reviews of medical necessity.

ERISA provides for internal review of claims denials in employer-based plans

Notice of rights when plan decides against you or after you finish internal review

May skip internal review in emergency or if plan doesn’t decide in 30 days

You can request external review within 4 mos

External review org (panel of medical experts assigned by insurance dept) reviews info from carrier, doctors, and you

External review org makes decision within 45 days (faster in emergency)

Carrier promptly complies if reversed

Many states: Can only appeal HMO decisions, not binding on plan, plans select own external reviewers, can only appeal costly claims, etc.

NAIC weaknesses: E.g., slow; too much weight to carriers re whether case moves on; no face-to-face hearings; no LEP requirements

Only appropriate for medical review Low success rate without assistance

Timelines for urgent, concurrent, pre-service, and post-service claims decisions

Written notice re reason for denial, plan care guidelines, review procedures, court rights

Can submit written evidence & review and copy plan evidence

Appeal within 180 days to person not involved in original decision; consults medical expert

Plan can have 2 levels of appeal before court

No external review except court in self-funded plans (though employer can reverse TPA)

Many people can’t afford lawyers and court

Senate: ◦ Internal and external review for all plans, initially

building on NAIC and ERISA standards and: Culturally/linguistically appropriate Right to present evidence and testimony Binding on health plan

House:◦ External review established by new

Commissioner; “de novo”

Not just medical – Did the person know? Did they commit fraud? Is treatment really related to pre-ex? Would insurer have sold the policy?

State best practices: ◦ Insurance dept always reviews prior to rescission◦ Appeals processes, right to present evidence

House: Independent, external review of recissions

Both: Eventually, medical underwriting and pre-ex exclusions are prohibited

Individual complaints – insurance dept sees whether approved rate was correctly applied

SOME states have rate hearings for SOME carriers

States can apply for grants to enhance rate review procedures; left to states re how they’ll conduct rate review and resolve consumer rate disputes before Exchange begins

DOL – reviews for plans 20 or more HHS – reviews for government plans and

mini-COBRA Paper review – you can submit documents,

they can call you with questions Determination within 15 days of receipt

Details left to rulemaking Senate: Secretary to establish procedures

(with other federal agencies) to “hear and make decisions”

Help available through consumer assistance/ombudsman programs

Senate: $30 million first year to establish, expand, support

Independent office or ombudsman in coordination with regulator/consumer assistance org

Helps consumers with appeals, enrollment, tax credit, rights and responsibilities

Collects data; reports re enforcement needs

Trade, industry… community and consumer-focused nonprofit, chamber of commerce…insurance agents and brokers…..◦ Public education/outreach – culturally appropriate◦ Enrollment help◦ Refer to consumer assistance/ombudsman for

further grievance help◦ No $ from insurers for enrollment in a plan

Your state can establish programs now! Workshop on Saturday…. Resources on http://www.familiesusa.org/health-reform-central/consumer-health-assistance-programs.html