Consumer Health Plan Appeals

Nov 6th, 2024

As part of the Patient Protection and Affordable Care Act (PPACA) of 2010, expanded appeal rights for patients have been granted in all states. These regulations grant the right to both an internal appeal through the insurance plan, as well as an independent external appeal.

Some states already have some consumer protection laws; however, the PPACA sets the minimum standard. Other provisions of this law also further extend patient protection in the following ways:

• Requiring insurance plans to give consumers detailed information about the denial along with information on how to appeal.
• Expedited appeals for urgent cases such as emergency room visits.
• Restricted appeal costs for the consumer. The health plan is responsible for the remainder of the appeal costs.

Plans that were in existence before implementation of this PPACA policy, that have not undergone substantial changes, are “grandfathered,” and will not be covered under the new rules. Nevertheless, you should still follow every appeal possibility.

Be aware that there is a federal law (i.e., Employee Retirement Income Security Act of 1974 [ERISA]) that sets the minimum requirements for private industry health plans. There may be additional help available if the patient’s insurance falls under ERISA.

Resource: See the ERISA Topics page for more information about ERISA.

Resource: See the “Grandfathered Plans” segment of the article “Healthcare Reform” for more information.

External Appeals

External appeals may be available with the health plan or insurance company payer with whom the patient is contracted. All states have various review boards to protect the public interest. External appeals or reviews refer to a formal dispute-resolution process that has the authority to evaluate and resolve disputes involving health care. Outside review panels are mandated to have no connection to the health plan. Each side in the dispute agrees to abide by the board’s decision, although in some states, patients may still sue a company if they’re not satisfied with the decision. You can check with your local association to find out how review boards operate in your state.

According to HealthCare.gov, “In urgent situations, you can request an external review even if you haven't completed all of the health plan's internal appeals processes.” Otherwise, an external review is not initiated until after exhausting all internal appeal levels.

Patients and providers might be hesitant to use the external review process; however, patients and their healthcare providers should take advantage of this process for resolving disputes that arise in obtaining appropriate care. Although this is still a relatively new concept, external review programs are popular with consumer advocacy groups. Some state laws encourage such a mediation process.