More Help on the Way for Health Care Consumers

When it comes to your health care, the most important thing is for it to be there for you when you need it – if you get sick or have an accident. 

For too long, patients have been forced to fend for themselves in a health care system that did not provide them with the support and assistance they needed and deserved. 

The Affordable Care Act is giving consumers new rights and resources to help them take control of their health care in good times and bad.  One of those new rights is the right to appeal decisions by your health plan to deny you benefits.

Under new rules, if you have coverage in a new plan, and your health plan denies coverage of a test – for example an MRI – you and your doctor can appeal that decision to the plan and to an independent, external reviewer.  If the external reviewer agrees with you, your plan must pay for the test.

If your plan decides to rescind your coverage altogether after you submit a claim, you can appeal that decision.  If your appeal is successful, the plan must reinstate your coverage.

If you go to the emergency room and your plan won’t pay the bill, you’ll have the chance to provide information to the plan about why you needed emergency care – and take your request to an external reviewer as well.

These rules will give consumers in new plans better information about what their rights are and why their claims were denied or coverage rescinded: 

• Right to information about why you’ve been denied.  Under the new rules, health plans and insurance companies have to tell you why they’ve decided to deny a benefit or end your coverage – and how you can appeal that decision.  And benefit denials and coverage rescissions are eligible for internal appeal. 
• Right to appeal to your insurance company.  If you’ve been denied a benefit or had your coverage rescinded, you have the right to an internal appeals process, or to appeal to your insurance company and receive a full and fair review of their decision.  If the case is urgent, your insurance company has to speed up the process.
• Right to an independent review.  Often, insurers and their policyholders can work out disputes during the internal appeal to their insurer.  If you can’t work it out through the internal process, now you have the right to take your appeal to an independent third-party for an external review of the decision.  This way, the insurance company no longer gets the final say and patients and doctors get more control over health care.

The new rules announced today apply to new plans that begin on or after September 23 of this year, and do not apply to plans and policies that are “grandfathered.”

HHS will not enforce these rules against issuers of stand-alone retiree-only plans in the private health insurance market.