The strengthened appeals rights are one of several common-sense consumer protections and insurance market reforms established by the Affordable Care Act. Having a meaningful appeals process ensures that you actually receive the benefits that your insurer has promised.
So, what exactly is an external review?
It means having an independent third party review your insurer’s decision, no matter where you live, thanks to the Affordable Care Act. Often, you can resolve disputes with your health plan by asking your insurer to reconsider its decision, in a process known as an “internal appeal.” But if, for example, your insurer still denies payment after the internal appeals process, you now can ask for an external review by an independent review organization to decide the matter. Insurance companies must accept the outcome of this external review. This means that your insurance company no longer gets the final say, and that patients and doctors get a greater measure of control over health care decisions.
These protections are important because when an insurer refuses to pay for a covered health care service, consumers could be faced with a large unplanned bill, and may not be able to afford the care their doctors say they need.
The Affordable Care Act sets these new important appeals standards for consumer protections and encourages States to take the lead in ensuring their own residents benefit from them. Where States have not yet passed laws implementing these consumer protections, HHS has set up a process to ensure that consumers in these States also benefit from the same protections and standards. If a State changes its external review process in the future, the State may request a new determination at any time.
Having DC, Massachusetts, New Hampshire, Ohio and Wisconsin step up to the plate to ensure consumers’ external review rights is a perfect example of how the Affordable Care Act empowers States to protect consumers.
By Eliza Bangit, Acting Director of the Consumer Support Group