Tags: New | Private | Health-Plan | Rules

New Private Health-Plan Rules

Tuesday, 21 November 2000 12:00 AM

According to Reuters news service:

The latest rules, issued Monday but not effective until a year from now, are intended to enable the more than 130 million Americans enrolled in employer-provided private health-care plans to obtain faster action on their medical claims and appeals.

Although in the works for two years, they are the direct result of a White House directive by President Clinton earlier this month after he could not persuade Congress to enact broader legislation extending access to specialists and emergency treatment and including the right to sue health plans over denials of care.

"This regulation cannot substitute for a Patients' Bill of Rights, but it can put in place fundamental safeguards at the earliest point in the process, when they can do the most good," said Leslie Kramerich, acting assistant secretary for the Pension and Welfare Benefits Administration.

Under these new rules:

• Employer-provided health plans will have only 15 days – down from 90 days currently – to decide on routine claims that must be authorized before treatment is provided.

• Urgent-care decisions must be made within 72 hours and left to patients' doctors, rather than health plans, to determine what is urgent.

• Health plans must consult with "appropriate health-care professionals" on appealed claims involving medical judgment.

• Appeals could not be decided by the same persons who denied the original requests.

• Patients will be allowed to sue to receive denied treatment if health plans fail to meet the new deadlines, but they may not seek damages for resulting injuries.

The new rules got mixed reactions.

Chip Kahn, president of the Health Insurance Association of America, said, "The regulations likely will cause employers' health-care costs to increase by millions of dollars, which will cause some employers to drop health coverage for workers."

But the American Association of Health Plans said the final rules appear to take into account some of the main objections raised by employers and insurers in September 1998.

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According to Reuters news service: The latest rules, issued Monday but not effective until a year from now, are intended to enable the more than 130 million Americans enrolled in employer-provided private health-care plans to obtain faster action on their medical claims...
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2000-00-21
Tuesday, 21 November 2000 12:00 AM
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