‘(d) Definitions- The Secretary, in consultation with the National Association of Insurance Commissions, shall establish uniform definitions for the activities reported under subsection (a).
‘SEC. 2719. APPEALS PROCESS.
‘A group health plan and a health insurance issuer offering group or individual health insurance coverage shall implement an effective appeals process for appeals of coverage determinations and claims, under which the plan or issuer shall, at a minimum--‘(1) have in effect an internal claims appeal process;
‘(2) provide notice to enrollees, in a culturally and linguistically appropriate manner, of available internal and external appeals processes, and the availability of any applicable office of health insurance consumer assistance or ombudsman established under section 2793 to assist such enrollees with the appeals processes;
‘(3) allow an enrollee to review their file, to present evidence and testimony as part of the appeals process, and to receive continued coverage pending the outcome of the appeals process; and
‘(4) provide an external review process for such plans and issuers that, at a minimum, includes the consumer protections set forth in the Uniform External Review Model Act (click here) promulgated by the National Association of Insurance Commissioners and is binding on such plans.’.
The Uniform External Review Model Act is being implemented as this bill becomes effective. Its purpose is to bring equity to all the appeal processes and hearing in regard to health care insurance. It is a good idea and brevity in that it takes review processes out of the hands of insurance companies that deny benefits to those Americans that need them. It will be an opportunity to weigh the benefits of 'value' and new technologies with investigative capacity to save lives as a component to value. It is necessary in today's Wall Street environment of draconian companies that view human beings as peasants as well as disposable people with families that will benefit from their life insurance rather than their HEALTH insurance.
SEC. 1002. HEALTH INSURANCE CONSUMER INFORMATION.
Part C of title XXVII of the Public Health Service Act (The states have no room to complain. There will be additional funding to provide support to its citizens as the health care insurance transitions to a user friendly structure.
‘SEC. 2793. HEALTH INSURANCE CONSUMER INFORMATION.
‘(a) In General- The Secretary shall award grants to States to enable such States (or the Exchanges operating in such States) to establish, expand, or provide support for--‘(1) offices of health insurance consumer assistance; or
‘(2) health insurance ombudsman (click here) programs.
‘(b) Eligibility-
‘(1) IN GENERAL- To be eligible to receive a grant, a State shall designate an independent office of health insurance consumer assistance, or an ombudsman, that, directly or in coordination with State health insurance regulators and consumer assistance organizations, receives and responds to inquiries and complaints concerning health insurance coverage with respect to Federal health insurance requirements and under State law.
‘(2) CRITERIA- A State that receives a grant under this section shall comply with criteria established by the Secretary for carrying out activities under such grant.
There is no reason for any State to ignore this opportunity to provide more support to their citizens in regard to health care insurance. There is not a case on record whereby State Regulators PREVENTED injury, deterioration or death of a citizen due to the draconian practices of the health insurance industry. This new law will provide every citizen with the opportunity to have health insurance and every State should rise to that directive and enforce the new standards.
The 'existing' review process through appeals is all contained within the health care insurance companies themselves and they have proven UNTRUSTWORTHY.
‘(c) Duties- The office of health insurance consumer assistance or health insurance ombudsman shall--
‘(1) assist with the filing of complaints and appeals, including filing appeals with the internal appeal or grievance process of the group health plan or health insurance issuer involved and providing information about the external appeal process;
‘(2) collect, track, and quantify problems and inquiries encountered by consumers;
‘(3) educate consumers on their rights and responsibilities with respect to group health plans and health insurance coverage;
‘(4) assist consumers with enrollment in a group health plan or health insurance coverage by providing information, referral, and assistance; and
‘(5) resolve problems with obtaining premium tax credits under section 36B of the Internal Revenue Code of 1986 click here).
This section is frequently accessed in bills other than health care reform to set appeal processes. This bill seeks sound content in existing law and the appeals process to health care with insurance companies are no different. These are procedures are familiar to corporate attorneys so the cost to any of this is negligible to an upstart. The corporations are now going to have to weigh their attorney costs along with providing care as they should to their peasants.
The down side to any of the appeal processes is that the peasant is suffering from illnesses that need attention NOW !
‘(d) Data Collection- As a condition of receiving a grant under subsection (a), an office of health insurance consumer assistance or ombudsman program shall be required to collect and report data to the Secretary on the types of problems and inquiries encountered by consumers. The Secretary shall utilize such data to identify areas where more enforcement action is necessary and shall share such information with State insurance regulators, the Secretary of Labor, and the Secretary of the Treasury for use in the enforcement activities of such agencies.
The above statute is quality control to focus on where appeals are mostly being conducted so the federal authorities can decide if the appeals are draconian and unnecessary to the peasants.
‘(e) Funding-
‘(1) INITIAL FUNDING- There is hereby appropriated to the Secretary, out of any funds in the Treasury not otherwise appropriated, $30,000,000 for the first fiscal year for which this section applies to carry out this section. Such amount shall remain available without fiscal year limitation.
$30 million US? That's all? Fine. Why do I especially feel like a peasant at this point?
‘(2) AUTHORIZATION FOR SUBSEQUENT YEARS- There is authorized to be appropriated to the Secretary for each fiscal year following the fiscal year described in paragraph (1), such sums as may be necessary to carry out this section.’.
This might be an improvement to the $30 million to initiate the quality assurance to the peasants in regard to their health care insurance. There are after all 50 states and other USA territories and native lands.
