Skip to main content

Advanced Search

Advanced Search

Current Filters

Filter your query

Publication Types



Newsletter Article


Proposed Rules Issued on Patient Appeals of Insurance Plan Denials

By Jane Norman, CQ HealthBeat Associate Editor

July 22, 2010 -- The Obama administration released on Thursday the interim final rules outlining how patients can make appeals if they are unhappy with a decision by their insurance company.

Under the new health care law (PL 111-148, PL 111-152), consumers will have processes available to them for appeals and claims internally within insurance companies, and to independent external review boards. The rules, now open for public comment, will apply to many plans beginning on or after Sept. 23 — though not all plans.

Phyllis Borzi, assistant secretary for the Department of Labor's Employee Benefits Security Administration, told reporters in a conference call that 31 million people in employer plans and 10 million in individual plans will benefit from the new standards in 2011.

Both group and individual plans will be covered, but not those that have been "grandfathered" in under the health care law, which means no major changes have been made in the plans since the March 23 passage of the law.

The proposal notes that as plans lose their grandfathered status in years to come, more will have to comply with the new federal appeals process. Borzi said the number of individuals covered by the new appeals rules is expected to rise to 88 million by 2013.

The rules will also apply to self-insured companies, which means the employer operates its own insurance plan and pays a third party to administer it.

External, third-party appeals of insurance decisions are now available in 44 states, and the processes and time limits for filing appeals vary. Many only cover HMOs. The new federal standards will replace that patchwork of protections, officials said, and make it simpler to file an appeal.

States can keep their external appeals processes but will have to update them to meet the new federal standards, and those patients whose states lack appeals laws can use the federal program. A study by the Kaiser Family Foundation found consumers won their external appeals 45 percent of the time under current state laws.

Plans will have to have an internal appeals process that allows consumers to appeal when they are denied a claim for a covered services or when coverage is canceled, gives them detailed information about the grounds for denials, notifies consumers that they have a right to appeal and tells them how, ensures a full and fair review and provides expedited appeals in urgent cases, according to an administration fact sheet.

The patient appeals announcement is the latest in a series highlighting the immediate benefits offered under the law, stressed by Democrats seeking to gain greater public acceptance for the overhaul. Other proposed rules have spelled out initiatives such as no cost-sharing for preventive care, insurance plan coverage for young adults and restrictions on policy cancellations for sick people.

The rules on appeals were announced by the departments of Health and Human Services, Labor and Treasury.

Also announced, by HHS, was the availability of $30 million in consumer assistance grants for states so that consumers can be educated about health care coverage. They are intended to help people enroll in programs, file complaints and appeals against health plans, track complaints and provide education. State attorneys general offices, insurance departments, consumer assistance agencies or other agencies are eligible. Information on the grants is at


Publication Details