External Review
A strong grievance and appeals process that includes the right to an external review—a review by an independent party—allows patients the ability to challenge limits on services. The Report Card examines whether state policy supports a patient’s right to challenge denial of care claims.
Health plans must give enrollees the right to an external review of health insurance plan decisions; this provision took effect in September 2010. "Grandfathered" plans--those that existed before the Affordable Care Act was passed--are exempt from this requirement, but plans will lose their grandfathered status if they significantly cut benefits, increase out-of-pocket spending, or change insurance carriers.
Does the state require managed care programs to provide patients with a right to external review of the managed care company’s decisions?
States receive a "meets policy" if they require managed care organizations to have an external review procedure. States receive a "no policy" if they have no such requirement.
| State | Strength of Policy | Change from 2007 |
|---|---|---|
| Alabama | Meets Policy | Same |
| Alaska | Meets Policy | Same |
| Arizona | Meets Policy | Same |
| Arkansas | Meets Policy | Same |
| California | Meets Policy | Same |
| Colorado | Meets Policy | Same |
| Connecticut | Meets Policy | Same |
| Delaware | Meets Policy | Same |
| District of Columbia | Meets Policy | Same |
| Florida | Meets Policy | Same |
| Georgia | Meets Policy | Same |
| Hawaii | Meets Policy | Same |
| Idaho | No Policy | Same |
| Illinois | Meets Policy | Same |
| Indiana | Meets Policy | Same |
| Iowa | Meets Policy | Same |
| Kansas | Meets Policy | Same |
| Kentucky | Meets Policy | Same |
| Louisiana | Meets Policy | Same |
| Maine | Meets Policy | Same |
| Maryland | Meets Policy | Same |
| Massachusetts | Meets Policy | Same |
| Michigan | Meets Policy | Same |
| Minnesota | Meets Policy | Same |
| Mississippi | No Policy | Same |
| Missouri | Meets Policy | Same |
| Montana | Meets Policy | Same |
| Nebraska | No Policy | Same |
| Nevada | Meets Policy | Same |
| New Hampshire | Meets Policy | Same |
| New Jersey | Meets Policy | Same |
| New Mexico | Meets Policy | Same |
| New York | Meets Policy | Same |
| North Carolina | Meets Policy | Same |
| North Dakota | Meets Policy | Same |
| Ohio | Meets Policy | Same |
| Oklahoma | Meets Policy | Same |
| Oregon | Meets Policy | Same |
| Pennsylvania | Meets Policy | Same |
| Rhode Island | Meets Policy | Same |
| South Carolina | Meets Policy | Same |
| South Dakota | No Policy | Same |
| Tennessee | Meets Policy | Same |
| Texas | Meets Policy | Same |
| Utah | Meets Policy | Same |
| Vermont | Meets Policy | Same |
| Virginia | Meets Policy | Same |
| Washington | Meets Policy | Same |
| West Virginia | Meets Policy | Same |
| Wisconsin | Meets Policy | Same |
| Wyoming | No Policy | Same |
Data Sources: 1) The Henry J. Kaiser Family Foundation, "Patients' Rights: External Review, 2008,” available at http://www.statehealthfacts.org/comparetable.jsp?cat=7&ind=361, accessed July 16, 2010; 2) National Women's Law Center, unpublished research, collected August 2010.
