Recent amendments apply standards of external review
Regulations were designed to provide uniform federal standards to govern consumers' right to appeal denials of claims or coverage by health plans.
Generally, courts require litigants to exhaust all administrative remedies before seeking judicial intervention. Thus, a claimant would be required to exhaust a plan's internal review processes before resorting to external review. Under the 2010 regulations, however, this administrative exhaustion requirement was relaxed such that a claimant could immediately seek external review of benefit denials if the plan failed to "strictly adhere" to all of the regulations' requirements for internal claims and appeals processes.
This amendment effectively removes the "strict" from "strict adherence" and perhaps is more indicative of a "substantial adherence" standard.
Medicaid Unwinding Linked to Prescription Loss in Children and Young Adults, Study Shows
May 2nd 2025Children and young adults living in states with the biggest drops in Medicaid coverage experienced more prescription disruptions for their chronic conditions than those living in states with smaller drops, according to a new study by researchers at the University of Michigan.
Read More
Conversations With Perry and Friends
April 14th 2025Perry Cohen, Pharm.D., a longtime member of the Managed Healthcare Executive editorial advisory board, is host of the Conversations with Perry and Friends podcast. His guest this episode is John Baackes, the former CEO of L.A. Care Health Plan.
Listen
Breaking Down Health Plans, HSAs, AI With Paul Fronstin of EBRI
November 19th 2024Featured in this latest episode of Tuning In to the C-Suite podcast is Paul Fronstin, director of health benefits research at EBRI, who shed light on the evolving landscape of health benefits with editors of Managed Healthcare Executive.
Listen
