State implementation of health reform consumer protection: preliminary determinations issued

The Center for Consumer Information and Insurance Oversight (CCIIO) has issued preliminary determinations for states in regard to the implementation of the external health claims review process required under the Affordable Care Act (ACA).

If states do not meet the minimum consumer protections of the Uniform Health Carrier External Review Model Act from the National Association of Insurance Commissioners (NAIC), insurance coverage becomes subject to the requirements of an external review process under federal standards.

States have the following options to implement the consumer protections:

• A state may meet the "strict standards" included in the interim final rules, which set forth 16 minimum consumer protections based on the NAIC model act;
• A state may operate an external review process under similar standards to those outlined in the interim final rule (these similar standards apply only until Jan. 1, 2014) or;
• If a state has implemented neither the "strict" standards nor the "similar" standards, issuers offering non-grandfathered plans and policies in the state will choose an HHS-administered process or contract with accredited independent review organizations to review external appeals on their behalf.

According to the August CCIIO determination, the following 23 states meet the "strict standard:" Arkansas, California, Colorado, Connecticut, Hawaii, Idaho, Illinois, Iowa, Kentucky, Maine, Maryland, Nevada, New Jersey, New York, Oklahoma, Oregon, Rhode Island, South Carolina, South Dakota, Utah, Vermont, Virginia, and Washington.

The following ten states meet the "similar standard:" Arizona, Delaware, Indiana, Kansas, Michigan, Minnesota, New Mexico, North Carolina, Tennessee, and Wyoming.

Seventeen states, according to CCIIO, as well as the District of Columbia, are subject to the HHS/independent review organization process: Alabama, Alaska, District of Columbia, Florida, Georgia, Louisiana, Massachusetts, Mississippi, Missouri, Montana, Nebraska, New Hampshire, North Dakota, Ohio, Pennsylvania, Texas, West Virginia, and Wisconsin.

Determinations are final if a state does not request a reconsideration of the preliminary determination. If a state requests reconsideration, final determinations will be made by Oct. 1, 2011. Additionally, if a state changes its external review process in the future, the state may request a new determination at any time.


For more information. For a comprehensive analysis of the Patient Protection and Affordable Care Act, including the full text of the law and additional information on health reform implementation and other recent developments in employee benefits, just click here.