Prior to the ACA, most states had legislation requiring an internal and external review process to allow consumers to appeal certain health plan decisions, such as denial of covered benefits. However, the level of consumer protections varied widely from state to state, and did not apply to self-insured employer plans, which left many consumers unable to seek recourse for denials of care by their insurers. The ACA sets, for the first time, minimum federal protections that all plans, including self-funded employer plans (but not grandfathered plans), must meet regarding appeals processes.
The ACA provides enrollees with a new national standard for appealing an unfavorable decision by a health plan. The new standard establishes a mandatory first-level internal appeals procedure administered by the health plan and then a second-level external appeals procedure administered by an independent third party. The ACA requires that the consumer get the following protections during each step of the process:
- An accessible appeal process at no cost to the consumer
- Continuation of health services and treatment throughout the appeals process
- A broad definition of what can be appealed
- A broad time frame for requesting the appeal
- Guaranteed assistance from a knowledgeable consumer advocate
- The selection of an external reviewer without a conflict of interest
- Full disclosure of the basis for the decision, in a timely fashion
- The collection and publication of appeals data for each health insurers, so consumers can view information about a health plan's record before deciding to enroll