Obamacare provides consumers with the ability to appeal claim denials with insurance companies. In addition, Obamacare allows states to require insurance companies to justify premium increases.
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SEC. 1311. AFFORDABLE CHOICES OF HEALTH BENEFIT PLANS.
(e) CERTIFICATION.—(1) IN GENERAL.—An Exchange may certify a health plan as a qualified health plan if—
(A) such health plan meets the requirements for certification as promulgated by the Secretary under subsection (c)(1); and
(B) the Exchange determines that making available such health plan through such Exchange is in the interests of qualified individuals and qualified employers in the State or States in which such Exchange operates, except that the Exchange may not exclude a health plan—
(i) on the basis that such plan is a fee-for-service plan;
(ii) through the imposition of premium price controls; or
(iii) on the basis that the plan provides treatments necessary to prevent patients’ deaths in circumstances the Exchange determines are inappropriate or too costly.
(2) PREMIUM CONSIDERATIONS.—As amended by section 10104(f)(1)¿ The Exchange shall require health plans seeking certification as qualified health plans to submit a justification for any premium increase prior to implementation of the increase. Such plans shall prominently post such information on their websites. The Exchange shall take this information, and the information and the recommendations provided to the Exchange by the State under section 2794(b)(1) of the Public Health Service Act (relating to patterns or practices of excessive or unjustified premium increases), into consideration when determining whether to make such health plan available through the Exchange. The Exchange shall take into account any excess of premium growth outside the Exchange as com- pared to the rate of such growth inside the Exchange, including information reported by the States.
(3) TRANSPARENCY IN COVERAGE.—As added by section 10104(f)(2)¿
(A) IN GENERAL.—The Exchange shall require health plans seeking certification as qualified health plans to submit to the Exchange, the Secretary, the State insurance commissioner, and make available to the public, accurate and timely disclosure of the following information:
(i) Claims payment policies and practices. (ii) Periodic financial disclosures. (iii) Data on enrollment. (iv) Data on disenrollment.
(v) Data on the number of claims that are denied. (vi) Data on rating practices. (vii) Information on cost-sharing and payments
with respect to any out-of-network coverage. (viii) Information on enrollee and participant
rights under this title. (ix) Other information as determined appropriate
by the Secretary.
SEC. 2794 [42 U.S.C. 300gg–94]. ENSURING THAT CONSUMERS GET VALUE FOR THEIR DOLLARS.
‘‘(a) INITIAL PREMIUM REVIEW PROCESS.—â€¨‘‘(1) IN GENERAL.—The Secretary, in conjunction with
States, shall establish a process for the annual review, beginning with the 2010 plan year and subject to subsection (b)(2)(A), of unreasonable increases in premiums for health insurance coverage.
‘‘(2) JUSTIFICATION AND DISCLOSURE.—The process established under paragraph (1) shall require health insurance issuers to submit to the Secretary and the relevant State a justification for an unreasonable premium increase prior to the implementation of the increase. Such issuers shall prominently post such information on their Internet websites. The Secretary shall ensure the public disclosure of information on such increases and justifications for all health insurance issuers.â€¨‘‘(b) CONTINUING PREMIUM REVIEW PROCESS.—
‘‘(1) INFORMING SECRETARY OF PREMIUM INCREASE PATTERNS.—As a condition of receiving a grant under subsection (c)(1), a State, through its Commissioner of Insurance, shall—
‘‘(A) provide the Secretary with information about trends in premium increases in health insurance coverage in premium rating areas in the State; and
‘‘(B) make recommendations, as appropriate, to the State Exchange about whether particular health insurance issuers should be excluded from participation in the Ex- change based on a pattern or practice of excessive or un- justified premium increases.â€¨‘‘(2) MONITORING BY SECRETARY OF PREMIUM INCREASES.—
‘‘(A) IN GENERAL.—Beginning with plan years beginning in 2014, the Secretary, in conjunction with the States and consistent with the provisions of subsection (a)(2), shall monitor premium increases of health insurance coverage offered through an Exchange and outside of an Ex- change.
‘‘(B) CONSIDERATION IN OPENING EXCHANGE.—In determining under section 1312(f)(2)(B) of the Patient Protection and Affordable Care Act whether to offer qualified health plans in the large group market through an Ex- change, the State shall take into account any excess of premium growth outside of the Exchange as compared to the rate of such growth inside the Exchange.
‘‘(c) GRANTS IN SUPPORT OF PROCESS.—â€¨‘‘(1) PREMIUM REVIEW GRANTS DURING 2010 THROUGH 2014.—
The Secretary shall carry out a program to award grants to States during the 5-year period beginning with fiscal year 2010 to assist such States in carrying out subsection (a), including—
‘‘(A) in reviewing and, if appropriate under State law, approving premium increases for health insurance coverage;
‘‘(B) in providing information and recommendations to the Secretary under subsection (b)(1); and
‘‘(C) [As added by section 10101(i)(1)(C)] in establishing centers (consistent with subsection (d)) at academic or other nonprofit institutions to collect medical reimbursement information from health insurance issuers, to analyze and organize such information, and to make such in- formation available to such issuers, health care providers, health researchers, health care policy makers, and the general public.â€¨‘‘(2) FUNDING.—
‘‘(A) IN GENERAL.—Out of all funds in the Treasury not otherwise appropriated, there are appropriated to the Secretary $250,000,000, to be available for expenditure for grants under paragraph (1) and subparagraph (B).
‘‘(B) FURTHER AVAILABILITY FOR INSURANCE REFORM AND CONSUMER PROTECTION.—If the amounts appropriated under subparagraph (A) are not fully obligated under grants under paragraph (1) by the end of fiscal year 2014, any remaining funds shall remain available to the Secretary for grants to States for planning and implementing the insurance reforms and consumer protections under part A.
‘‘(C) ALLOCATION.—The Secretary shall establish a formula for determining the amount of any grant to a State under this subsection. Under such formula—
‘‘(i) the Secretary shall consider the number of plans of health insurance coverage offered in each State and the population of the State; and
‘‘(ii) no State qualifying for a grant under paragraph (1) shall receive less than $1,000,000, or more than $5,000,000 for a grant year.
‘‘(A) develop fee schedules and other database tools that fairly and accurately reflect market rates for medical services and the geographic differences in those rates;
‘‘(B) use the best available statistical methods and data processing technology to develop such fee schedules and other database tools;
‘‘(C) regularly update such fee schedules and other database tools to reflect changes in charges for medical services;
‘‘(D) make health care cost information readily available to the public through an Internet website that allows consumers to understand the amounts that health care providers in their area charge for particular medical services; and
‘‘(E) regularly publish information concerning the statistical methodologies used by the center to analyze health charge data and make such data available to researchers and policy makers.â€¨‘‘(2) CONFLICTS OF INTEREST.—A center established under subsection (c)(1)(C) shall adopt by-laws that ensures that the center (and all members of the governing board of the center) is independent and free from all conflicts of interest. Such by- laws shall ensure that the center is not controlled or influenced by, and does not have any corporate relation to, any individual or entity that may make or receive payments for health care services based on the center’s analysis of health care costs.
‘‘(3) RULE OF CONSTRUCTION.—Nothing in this subsection shall be construed to permit a center established under sub- section (c)(1)(C) to compel health insurance issuers to provide data to the center.’’.
SEC. 2719 [42 U.S.C. 300gg–19]. APPEALS PROCESS. [Replaced by section 10101(g)]
‘‘(a) INTERNAL CLAIMS APPEALS.—
‘‘(1) IN GENERAL.—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—
‘‘(A) have in effect an internal claims appeal process;
‘‘(B) 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; and
‘‘(C) 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.â€¨‘‘(2) ESTABLISHED PROCESSES.—To comply with paragraph
(1)—‘‘(A) a group health plan and a health insurance issuer offering group health coverage shall provide an internal claims and appeals process that initially incorporates the claims and appeals procedures (including urgent claims) set forth at section 2560.503–1 of title 29, Code of Federal Regulations, as published on November 21, 2000 (65 Fed. Reg. 70256), and shall update such process in accordance with any standards established by the Secretary of Labor for such plans and issuers; and
‘‘(B) a health insurance issuer offering individual health coverage, and any other issuer not subject to sub- paragraph (A), shall provide an internal claims and appeals process that initially incorporates the claims and ap- peals procedures set forth under applicable law (as in existence on the date of enactment of this section), and shall update such process in accordance with any standards established by the Secretary of Health and Human Services for such issuers.
‘‘(b) EXTERNAL REVIEW.—A group health plan and a health insurance issuer offering group or individual health insurance coverage—
‘‘(1) shall comply with the applicable State 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 promulgated by the National Association of Insurance Commissioners and is binding on such plans; or
‘‘(2) shall implement an effective external review process that meets minimum standards established by the Secretary through guidance and that is similar to the process described under paragraph (1)—
‘‘(A) if the applicable State has not established an external review process that meets the requirements of paragraph (1); or
‘‘(B) if the plan is a self-insured plan that is not subject to State insurance regulation (including a State law that establishes an external review process described in paragraph (1)).
‘‘(c) SECRETARY AUTHORITY.—The Secretary may deem the external review process of a group health plan or health insurance issuer, in operation as of the date of enactment of this section, to be in compliance with the applicable process established under sub- section (b), as determined appropriate by the Secretary.