New rules affect patients’ insurance appeals

Kaiser Health News’ Phil Galewitz and Michelle Andrews have an update on health care reform implementation, pointing out that new rules will give consumers the right to appeal insurance denials, first directly to the insurer and then to review boards. The rule doesn’t break new ground in most states – only five lack such regulations, and existing plans are “grandfathered in” under the old rules – but it may bring order to a chaotic national patchwork on insurance appeals. The White House estimates that, by next year, the rules will benefit about 41 million Americans insured either through employers or through individual plans. The administration is pushing states to implement the new standards by next July.

The new regulations take effect for plan years starting Sept. 23. But they won’t automatically apply to residents in states that have existing external review laws until next July. That’s to give states time to adjust to the new standards.

If states fail to change their rules by next July, their residents will then be able to rely on the federal standards. But federal officials are still working out the details of how that would be done.

Read the HHS press release here.

AHCJ resources

  • Reporting on health reform between now and 2014: Some top Washington, D.C.-based journalists discussed implementation deadlines, how to tie local issues to reform, Medicare reimbursement rates, what reporters should look for in their states and more. A recording and transcript of this briefing and a resource list are available.
  • Covering high-risk insurance pools: The federal government and states are scrambling to create temporary high-risk pools for the medically uninsurable, as one of the first provisions of the Patient Protection and Affordable Care Act to go into effect. Apart from being a policy story, it’s of great interest to all your readers, viewers or listeners who have pre-existing conditions and are struggling to find coverage. Four reporters covering the topic have shared their story tips, suggestions and resources for AHCJ members.
  • Health care reform has passed: What’s next? Four journalists on the front lines offer their advice and suggestions on what needs to be covered next, how it might affect local communities and how to approach this complex topic.

1 thought on “New rules affect patients’ insurance appeals

  1. Angel M. Garcia, M.D.

    Dear Andrew,
    I have been practicing primary care medicine in the US for 26 years. I have seen the quality of medicine deteriorate over the years while the cost continues to rise sharply. I have done research via NCQA government statistics to see where and how we can reduce our national healthcare costs while at the same time improve the quality of our care. Much to my dismay, my research shows that 30% of our healthcare costs are spent on preventable illnesses such as Heart Attacks, Strokes and the like. This means that about $ 720 Billion per year could be saved if we could detect the patients with early symptoms and signs prior to developing the complications of chronic illness. I have articles that I have written regarding this topic. I would be happy to provide them to you for your review. Please visit my web site at for further information on how we can truly transform healthcare in the US. Warm regards, Dr. Garcia

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