States have the option to have an external review process, which could help assure that review takes into account state specific policies and circumstances, or defer this consumer protection responsibility to the federal government.

*Milestone details:

*Milestone full name: Determine whether to establish or update if necessary a state external review process for insurance plan determinations, or instead let federal regulations govern.

*Relevance to the ACA:

The ACA requires insurers to adopt an appeals process for the individual and group market. Insurance issuers are required to either comply with states’ external review processes where they exist or to establish processes that comply with federal regulations. Relevant provisions include:

§1001 - Requires an external review process for individual and group market plans effective plan years after September 2010. Plans at a minimum must meet state standards that include the NAIC’s Uniform External Review Model Act or regulations promulgated by the Secretary of HHS if the state does not have an external review process or the plan is self-funded.

§1321 - Amends the Public Health Service Act provisions on state enforcement authority regarding group health plans to include regulation of the individual market, allowing the federal government to preempt state law and enforce the consumer protections if states do not.