Insurers in 15 states could be subject to HHS appeals review

Fifteen states and the District of Columbia fail to meet requirements for consumer appeals of health plan coverage decisions, according to the federal body in charge of enforcing the health system reform law.

The Center for Consumer Information & Insurance Oversight said in those jurisdictions, as well as five U.S. territories, insurers will have to pay for independent external review or be subject to a standard federal appeals process. The center said state law does not provide a sufficient third-party appeals process. States have until Jan. 1, 2012, to make fixes.

The affected states are Alabama, Alaska, Florida, Georgia, Louisiana, Massachusetts, Mississippi, Missouri, Montana, Nebraska, North Dakota, Ohio, Pennsylvania, Texas and West Virginia.

Robert Zirkelbach, spokesman for trade group America's Health Insurance Plans, declined to comment on the HHS decisions, saying the determinations were a "state issue."

Under the Patient Protection and Affordable Care Act, insurers must guarantee subscribers both internal and external review for denials or adverse coverage decisions. The reform law says consumers must be protected at least to the degree laid out in a model external review state law as last amended by the National Assn. of Insurance Commissioners in 2010.

Among other things, the health reform law requires insurers to notify customers of their right to appeal, explain the process in non-English languages in certain circumstances, and maintain coverage for an enrollee while an appeal is pending. The law gives customers the right to present evidence and testimony in support of their appeal before an independent reviewer.

Where state laws provide external review protections but don't meet the standards laid out in the reform law, HHS has given states with "similar" rules until January 2014 to enact laws that meet the new threshold.

States with external review laws deemed inadequate may ask HHS to reconsider its decision at any time.

In comments sent July 25, the American Medical Association urged HHS to strengthen consumer protections in the external review rules, including giving patients 120 days to appeal after receiving a notice of denial.