PPACA Paper 1) Use your critical thinking skills to write a paper of 1,000–1,200 words that responds to the question, "Is the PPACA legislation an improvement or a liability to our health care deliver
10/16/2019 Affordable Care Act: W orking with States to Protect Consumers - Centers for Medicare & Medicaid Serviceshttps://www.cms.gov/CCIIO/Resources/Files/working_with_states_to_protect_consumers_0622201 1.html 1/2
The C en te r f o r C onsu m er In fo rm atio n & In su ra n ce O vers ig ht
A ffo rd ab le C are A ct: W ork in g w it h S ta te s t o P ro te ct C onsu m ers
T he A ff o rd able C are A ct e sta blis hes c o m mon -s e nse c o nsu m er p ro te ctio ns a nd r e quire s in su re rs to o pera te in a m ore
tr a nsp are nt m anner. F air r u le s a nd tr a nsp are ncy h elp c re ate a m ore le ve l p la yin g fie ld b etw ee n c o nsu m ers a nd
in su re rs . T he la w a ls o e m pow ers S ta te s b y p uttin g th em in th e d riv er’s s e at in im ple m entin g m any o f th ese n ew
co nsu m er p ro te ctio ns.
O n J u ly 2 3, 2 010, th e D epartm ents o f H ealth a nd H um an S erv ic es, L abor, a nd th e T re asu ry is su ed a n in te rim f in al ru le
re gard in g in te rn al cla im s a nd a ppeals a nd e xte rn al re vie w p ro ce sse s fo r g ro up h ealth p la ns a nd h ealth in su ra n ce
is su ers o ff e rin g c o ve ra ge in th e g ro up a nd in div id ual m ark e ts . T his r u le w ork s to g iv e p eople in m ost p la ns b ette r
in fo rm atio n a bout w hat th eir r ig hts a re a nd w hy th eir c la im s w ere d enie d o r c o ve ra ge r e scin ded. U nder t h e r u le ,
co nsu m ers h ave th e:
R ig ht t o in fo rm atio n a b out w hy a c la im o r c o vera g e h as b een d en ie d . H ealth p la ns a nd in su ra nce c o m panie s
have to te ll yo u w hy th ey’v e d ecid ed to d eny a c la im o r c h ose n to e nd y o ur c o ve ra ge – a nd h ow y o u c a n a ppeal
th at d ecis io n.
R ig ht t o a p peal t o t h e in su ra n ce c o m pan y. If y o u’v e h ad a c la im d enie d o r h ad y o ur c o ve ra ge r e scin ded, y o u
have th e r ig ht to a n in te rn al a ppeals p ro ce ss, a p ro ce ss in w hic h y o u a sk y o ur in su ra nce c o m pany to c o nduct a fu ll
and fa ir r e vie w o f it s d ecis io n. If th e c a se is u rg ent, y o ur in su ra nce c o m pany m ust s p eed u p th is p ro ce ss.
R ig ht t o a n in dep en den t r e vie w . O fte n, in su re rs a nd th eir p olic yh old ers c a n r e so lv e d is pute s d urin g th e in te rn al
appeals p ro ce ss. If y o u c a n’t w ork it o ut th ro ug h th e in te rn al a ppeals p ro ce ss, y o u n ow h ave th e r ig ht to ta ke y o ur
appeal to a n in dependent th ird -p arty fo r r e vie w o f th e in su re r’s d ecis io n. T his is c a lle d “ e xte rn a l re vie w.” T his w ay,
th e in su ra nce c o m pany n o lo nger g ets th e fin al sa y r e gard in g y o ur b enefit s, a nd p atie nts a nd d octo rs g et a g re a te r
m easu re o f c o ntr o l o ve r h ealth c a re
T hese p ro te ctio ns a nd s ta ndard s a re a n im po rta nt s te p fo rw ard in r e fo rm ing th e h ealth c a re s yste m to m ake s u re it
w ork s fo r c o nsu m ers , n ot ju st in su ra nce c o m panie s.
A m en ded IF R : S ta te F le xib ilit y a n d T ra n sit io n t o 2 014
To day th e D epartm ents a re a m endin g th e J u ly 2 3, 2 010 In te rim F in al R ule . A m endm ents to th e IF R m ain ta in th e
unpre ce dente d c o nsu m er p ro te ctio ns p ro vid ed in th e A ff o rd able C are A ct w hile r e fle ctin g c o m ments fr o m s ta ke hold ers
a nd g iv e S ta te s th e fle xib ilit y th ey n eed to im ple m ent th e la w.
The J u ly 2 010 IF R s e t fo rth 1 6 m inim um c o nsu m er p ro te ctio ns b ase d o n th e U nifo rm H ealth C arrie r E xte rn a l R evie w
M odel A ct w rit te n b y th e N atio nal A sso cia tio n o f In su ra nce C om missio ners ( N AIC ) th at, if p ro vid ed b y a S ta te e xte rn a l
re vie w p ro ce ss, w ill re su lt in th e S ta te s’ p ro ce ss a pply in g in lie u o f a F edera l e xte rn al re vie w p ro ce ss.
M any S ta te s h ave m ade p ro gre ss in m eetin g th e m inim um s ta ndard s la id o ut in th e J u ly 2 3, 2 010 IF R . T o g iv e S ta te s a
r e aso nable o pportu nity to c o ntin ue to im ple m ent th ese im porta nt c o nsu m er p ro te ctio ns th e a m ended IF R e xte nds th e
tr a nsitio n p erio d fo r S ta te e xte rn al re vie w p ro ce sse s to J a nuary 1 , 2 012.
D urin g th e tr a nsitio n p erio d ( u ntil Ja nuary 1 , 2 0 12), a t a m inim um , p la ns a nd is su ers a re e xp e cte d to fo llo w th eir S ta te
la ws a nd p ro ce sse s fo r e xte rn al re vie w in th e S ta te s in w hic h th ey a re o pera tin g. P la ns a nd is su ers in S ta te s a nd
te rrit o rie s w here th e H HS-a dm iniste re d F edera l e xte rn al re vie w p ro ce ss a lre ady a pplie s a s o f th e d ate o f th is g uid ance
a re e xp ecte d to c o ntin ue th eir p artic ip atio n in th e F edera lly -a dm iniste re d e xte rn al re vie w p ro ce ss u ntil HHS d ete rm ines
oth erw ise.
In a dditio n, s e para te g uid ance b ein g is su ed c o nte m pora neously w ith th e p ublic atio n o f th is a m endm ent a nnounce s
sta ndard s u nder w hic h, u ntil Ja nuary 1 , 2 014, a S ta te m ay o pera te a n e xte rn al re vie w p ro ce ss u nder F edera l sta ndard s
sim ilar to th e r e quire d c o nsu m er p ro te ctio ns o u tlin ed in th e J u ly 2 3, 2 010 IF R . U nder th is g u id ance , if H HS d ete rm ines
th at a S ta te h as n eith er im ple m ente d th e r e qu ire d c o nsu m er p ro te ctio ns n or im ple m ente d a p ro ce ss th at m eets th e
F edera l sta ndard s th at a re s im ilar to th e r e quir e d c o nsu m er p ro te ctio ns, is su ers in th e S ta te w ill have th e c h oic e o f
partic ip atin g in e ith er th e H HS-a dm iniste re d e xte rn al re vie w p ro ce ss o r c o ntr a ctin g w ith a cc re d ite d In dependent R evie w
Org aniz atio ns. T his g uid ance a ls o p hase s in th e u se o f m ultip le In dependent R evie w O rg aniz atio ns fo r t h e p la ns th at
use th em s ta rtin g n ext y e ar a s a w ay o f e nsu rin g th at th e e xte rn al re vie w is u nbia se d.
H HS is a doptin g th is a ppro ach to p erm it S ta te s to o pera te th eir e xte rn al p ro ce sse s u nder s ta ndard s e sta blis hed b y th e
S ecre ta ry u ntil Ja nuary 1 , 2 014 to a vo id u nnece ssa ry d is ru ptio n w hile S ta te s w ork to a dopt th e c o nsu m er p ro te ctio ns
C CIIO H om e > A ff o rd able C are A ct: W ork in g w it h S ta te s to P ro te ct C onsu m ers
10/16/2019 Affordable Care Act: W orking with States to Protect Consumers - Centers for Medicare & Medicaid Services
https://www.cms.gov/CCIIO/Resources/Files/working_with_states_to_protect_consumers_0622201 1.html 2/2
A fe dera l g ove rn m ent w ebsite m anaged a nd p aid fo r b y th e U .S . C ente rs fo r M edic are &
M edic aid S erv ic es. 7 500 S ecu rit y B oule va rd , B altim ore , M D 2 1244
se t fo rth in th e J u ly 2 010 r e gula tio ns. S ta rtin g in 2 014, th e a ppeals p ro ce ss w ill be m ore c lo se ly a lig ned a cro ss a ll
ty p es o f p la ns.
A ddit io nal A m en dm en ts t o t h e IF R :
The a m ended IF R r e le ase d to day in clu des d eta ils o f a ll of th e c h anges m ade fr o m th e o rig in al IF R . Y ou c a n fin d th e
te xt o f th is a m ended IF R here .
A dditio nal g uid ance is su ed c o nte m pora neously w ith th e p ublic atio n o f th e a m ended IF R c a n b e fo und here .