June 10th, 2011

Kaiser Health News reports:

Millions of Americans gained the right this year to appeal decisions made by health plans to an outside, independent decision-maker. But many of these consumers might not know they have the new option — and when they find out, it might be too late.

Federal officials say that, beginning this year, about 44 million people are entitled for the first time to an external appeal, under the 2010 health care law. They are enrolled in self-insured health plans offered through an employer that weren’t grandfathered, or exempted, under the law. Employers with self-insured health plans pay for claims from their own funds instead of through insurance companies, although they often have insurers administer the plans.

In an external review, consumers who have been denied coverage make their cases to an arbiter — who has no financial stake in the decision — that the medical services are necessary and should be paid for by the health plan. A study by the Government Accountability Office this year found that consumers in plans already offering these outside reviews prevailed in as many as 54 percent of the cases. Under the health law, the employer or insurer is required to hire an outside review organization that takes a fresh look at the case and must follow a strict time frame for processing the appeal. The decision is final and the insurance plan must follow it.

The provision took effect for most plans Jan. 1. But in response to self-insured plans’ concerns about being able to meet some of the requirements, the government said it wouldn’t require the plans to tell members about their external appeals rights until plan years beginning after July 1. Since most plans start their new year in January, that means they won’t have to notify members about their right to external appeals and how to file them until next year.

However, the government isn’t granting enrollees more time to file appeals, said an official at the Department of Health and Human Services, who spoke only on the condition of not being identified. Patients have 180 days from the date of initial denials to file internal appeals to the plan. If the appeals are rejected, they then have another four months to appeal to outside arbiters.

For the rest of the story read Kaiser Health News