1. The Affordable Healthcare Act – Interim Final Regulations for Internal Claims
and Appeals and External Review
September 8, 2010
DRAFT
To Whom It May Concern:
The National Council for Community Behavioral Healthcare (National Council) is pleased to
respond to the Interim Final Regulations for Internal Claims and Appeals and External
Review Processes.
The National Council, a non-profit association representing over 1,700 community mental
health centers and other community-based mental health and addiction providers, is dedicated
to fostering clinical and operational innovation and promoting policies that ensure more than
6 million low-income children, adults, and families our members serve have access to high
quality services. Our community mental health and addiction organizations have more than
40 years of experience and expertise in providing a range of clinic-based services and
recovery supports for millions of individuals with multiple chronic health problems.
While many of our member agencies primarily serve consumers through Medicaid,
Medicare, and grant-based funding, a significant number of our clients have private health
insurance. Our member agencies are dedicated to helping consumers navigate often unclear,
inconsistent, and confusing rules to ensure that consumers secure reimbursement for services
important to their mental and physical health. These regulations take an important step in
establishing a baseline of protections for healthcare consumers, and will hopefully enable
healthcare providers to help consumers navigate the healthcare system more effectively.
In any given year, about 4.4 percent of adults have a serious mental disorder, and 8.3 percent
of youths between ages 12 and 17 have at least one major depressive episode. In 2008, 8.3
million adults had suicidal thoughts, and almost nine percent of the population suffered from
substance abuse or dependence.i These numbers represent a significant portion of the U.S.
population that need services to treat mental illness or addiction. Although a range of
efficacious treatments is available to address symptoms of mental illnesses and substance use
disorders, financial barriers often stand in the way of accessing effective treatment. For
example, among the 5.1 million adults who reported having unmet need for treatment for
mental health problems in 2008, more than half reported cost or insurance issues as a barrier
to receiving treatment.ii In a recent survey, primary care physicians have indicated that lack
of access to mental health services is a serious problem—much more serious than for other
commonly used medical services; two-thirds of PCPs in the study could not obtain mental
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2. health services for at least some of their patients, a rate that was twice as high as for referrals
to other specialists.iii
In the backdrop of these statistics, the Federal government recently released interim final
regulations on the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction
Equity Act. This law and these regulations will hopefully address many of the barriers to
treatment that people with mental illnesses and addictions face. We hope that the
Departments will make every effort to keep the spirit of the Parity Act in mind as they
finalize rules for the Affordable Healthcare Act. With only the recent passage of the parity
law, the National Council is especially attuned to the potential for people with mental
illnesses and/or addictions to be denied care.
The internal claims and appeals and external review procedures provide consumers with
recourse when plans deny reimbursement for care. It is not well understood how often
internal claims and appeals are used, but we do know that external reviews are seldom used,
even though nearly 50 percent of appeals result in favor of the consumer.iv Surveys suggest
that consumers face problems with accessing their healthcare in greater numbers than current
numbers suggest. The National Council is concerned that consumers do not have enough
information about their rights, that barriers deter them from obtaining the care they need and
that States do not have proper mechanisms to enforce the protections in place. Furthermore,
the National Council believes that people with mental illnesses or substance use disorders
may have particular difficulty navigating complex appeals processes.
The National Council strongly encourages the Departments to use these and future
regulations on this topic to:
A. Increase transparency about plan decision-making
B. Reduce barriers to the appeals process
C. Provide adequate supports to State insurance commissioners and consumer assistance
offices to ensure effective enforcement of the law.
Increase Transparency
A lack of transparency about medical decision-making and plan policies has made it
particularly challenging to understand how to improve internal claims and appeals and
external review processes. The National Council supports efforts by the regulations to clarify
the process for consumers, as well as the health providers who help them.
Transparency about the Process
The National Council supports stronger language requiring plans to include information
about both internal and external review processes in plan marketing materials, plan websites,
and plan information toll-free numbers. In addition, the National Council recommends that
the regulations require plans to include the necessary forms with any adverse determination
letters. Most importantly, plans must be required to inform consumers about their right to
both internal and external appeals at the first adverse determination.
Rationale for Adverse Determination
The National Council approves regulation requirements that plans must provide clear
information about how a decision is reached and the basis for that decision, and that plans
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3. must now inform consumers about any new information regarding the determination.
Requiring plans to provide a rationale for their decision-making and to clearly explain the
basis for those decisions will incentivize the provision of appropriate care. These rules make
an important step in making insurance plans more transparent.
The National Council is concerned that some plans will continue using medical necessity
criteria to limit access to necessary care, and urges the Departments to continue to strengthen
transparency requirements for adverse determinations. Since insurance plans have not always
had to be transparent about their medical necessity criteria, both consumers and providers
have not been able to appeal adverse determinations effectively.
Further, the Departments should continue to require plans to ensure that medical necessity
criteria are reasonable. As regulations for the Paul Wellstone and Pete Domenici Mental
Health Parity and Addiction Equity Act go into effect, the National Council is acutely aware
how narrow definitions of medical necessity have limited access to mental health and
addiction services. A narrow definition may not recognize valid mental illnesses, such as
post-traumatic stress disorder, as requiring services. Other definitions may require an
unreasonable duration of symptoms before a person qualifies for care. For people with
mental illnesses and addictions, it is critically important to break down barriers to care. The
stronger transparency requirements and clear direction that criteria be reasonable will make
an important improvement in establishing strong consumer protections.
The National Council urges the Departments to strengthen the language in the regulations to
make sure that all plans must be transparent in how they have made medical decisions, and to
specifically require that plans make medical necessity criteria available to both providers and
to consumers.
Consumer Rights
Expedited Process for Emergency Situations. The National Council strongly supports the
reduction of decision-making time to 24 hours for medical emergencies for both internal and
external appeals. For people in psychiatric crisis, it is critically important to facilitate access
to care, particularly when individuals are in psychiatric crisis. Any effort to make coverage
decisions more responsively will enable providers to ensure that consumers receive the
treatment they need.
Internal Appeals. The National Council supports regulations that individual health plans may
only have one level of internal appeals before moving to an external appeals process.
Research suggests that an external appeals process provides a more objective review of the
medical evidence, and that consumers are more likely to have their cases overturned in
external reviews.v Further, requiring consumers to go through multiple levels of internal
claims and appeals may serve as an ongoing barrier to necessary care. Therefore, the
National Council suggests that the Departments change the regulations so that all health plans
may have only one level of appeal before moving to an external review process. Multiple
levels of internal reviews only serve as a deterrent for consumers to access care that they
need.
At the very least, the National Council recommends that people with mental illnesses and
addictions be exempted from requirements to exhaust internal claims and appeals processes.
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4. This exemption would ensure the appropriate implementation of the new parity law and
would minimize the impact on people with mental illness. There is precedent for this in
Minnesota, where the attorney general had to require youth with mental illness be exempt
from internal review processes due to a lawsuit.vi
Filing Fee. The IFR allows a $25 filing fee for external reviews, with a maximum of $75 per
year. Most States do not allow consumers to be charged a filing fee, and the National
Council objects to the regulations allowing this fee. The fee does not cover the costs of the
external review (estimated at $605 by the Departments), and therefore, only serves as a
barrier to the review process. Since so few consumers utilize the external review process,
this seems like an unnecessary use of utilization management.
The National Council is pleased to see that a maximum annual cost has been established and
that the fee should be waived for financial duress. However, the IFR does not define
“financial duress,” and we are concerned that these costs could serve as a deterrent for some
consumers. While many individuals with private insurance can comfortably pay an
additional $25, there is a critically important minority for which this cost would prevent them
from utilizing the appeals process. For example, in 2010, a family of four who earns
$33,075.00 will be at 150% of the Federal Poverty Level.vii This breaks down to $2,480.63
per month to pay for housing, food, insurance, gas, clothing and other necessities for four
people. Families with this kind of budget might have private health insurance, but would
have difficulty with additional fees. The National Council proposes that the Departments
provide some guidance to plans in determining financial duress.
The National Council understands that the States are not required to charge a filing fee, but
we recommend that the Departments make every effort to discourage their use. In addition,
the Departments should require plans to inform consumers that the $25 filing fee will be
reimbursed to the consumer if he or she wins the appeal.
Review Responses. Currently, the IFR do not address circumstances in which either the
internal review process or the external review process overturns a portion of a medical
decision. Given the complexity of medical practice, the National Council strongly
encourages the Departments to add language permitting nuanced responses to medical cases
in both internal and external reviews.
Regulation Impact. The Departments requested comments on whether the Federal external
review process should apply to all plans and issuers in a State if the State external review
process does not apply to all issuers in a State. The National Council contends that the
regulations should continue to serve as a baseline of protections, not a ceiling. Any
protections in a State stronger than those outlined in the Federal external review process
should not be superseded.
At the same time, the National Council recognizes that there are inconsistent protections
within States as well as across State lines, increasing the complexity of implementation of
these regulations. If a state has different standards for different issuers, the Departments
should give the State until July 1, 2011 to resolve those differences, and may need to work
with States to provide model language and regulatory guidance. If a State does not modify
its own laws to cover its entire population, then the State will have to be responsible for
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5. monitoring two different standards. However, if the existing protections for the population
(e.g., managed care only) are weaker than the Federal regulations, then the new Federal law
would cover the entire population in the State.
Implementation
The Departments are planning to rely on State Insurance Commissioners and State Consumer
Affairs offices to enforce and assist in the implementation of these new regulations. The
National Council applauds the plans to provide model forms and language as well as
implementation grants to consumer assistance offices. In addition, it is appropriate to
provide time to the States to enforce these new rules. However, the National Council is
concerned that these offices may not have the capacity to enforce these new regulations
effectively. Less than half of States have consumer assistance offices, and insurance
commissioner offices are often small.viii We strongly encourage the Departments to provide
as much guidance and technical support as possible.
In addition, health providers are often a crucial link for both internal appeals and external
review processes. Yet, they are not mentioned in the regulations at all. The National Council
urges the Departments to amend the regulations to require that plans make all internal and
external appeals process information and forms available to health providers. In addition,
health providers should be included in all information packets for both consumer affairs and
insurance commissioner offices. Finally, the National Council recommends that providers be
included in the consumer assistance grants or that the Departments issue an additional set of
provider assistance grants. The National Council is committed to the health of its clients and
would like every opportunity to ensure that our members can support consumers in accessing
the care they need.
We thank you for the opportunity to comment on the Interim Final Regulations for Internal
Claims and Appeals and External Review.
Sincerely,
Linda Rosenberg
President/CEO
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6. i
Substance Abuse and Mental Health Services Administration. (2009). Results from the 2008 National Survey on Drug Use
and Health: National Findings (Office of Applied Studies, NSDUH Series H-36, HHS Publication No. SMA 09-4434).
Rockville, MD.
ii
Id.
iii
Beyond Parity: Primary Care Physicians’ Perspectives On Access To Mental Health Care Peter J. Cunningham, Health
Affairs, 28, no. 3 (2009): w490-w501, (Published online 14 April 2009), doi:10.1377/hlthaff.28.3.w490.
iv
Pollitz, Karen, Crowley, Jeff, Lucia, Kevin, and Eliza Bangit (Revised May 2002).
“Assessing State External Review Programs and the Effects of Pending Federal Patients’ Rights Legislation.” Georgetown
University, Institute for Healthcare Research and Policy. Prepared for the Henry J. Kaiser Family Foundation.
http://www.kff.org/insurance/externalreviewpart2rev.pdf
v
Pollitz, et al. (2002).
vi
Id.
vii
https://www.cms.gov/MedicaidEligibility/downloads/POV10Combo.pdf
viii
M anaged C are St at e Laws and R egul at i ons , In cl udi ng Cons um er and P rovi der P rot e ct i ons . National
Conference of State Legislators. Updated: March 2008; Reposted May 2010.
http://www.ncsl.org/default.aspx?tabid=14320.