The Regulation of the Individual Health Insurance Market. Endnotes


[1] ERISA outlines minimum federal standards for private employer-sponsored benefits such as requiring a plan administrator to provide a summary of plan benefits to employees, file annual reports, maintain procedures for claiming benefits and provide administrative and judicial remedies for beneficiaries.  HIPAA was enacted to address concerns that insured persons have about losing their coverage if they change jobs or health plans.  HIPAA established federal requirements to ensure the availability and renewability of coverage for certain employees and other persons under certain circumstances.

[2] External review laws provide consumers with a mechanism to resolve coverage disputes when a health insurance plan determines that a proposed service or treatment does not meet medical necessity criteria or is experimental or investigational.  Typically, external review programs are operated by a state’s Department of Insurance, and apply to health insurance plans regulated by the state.  While state regulators usually determine the eligibility of an external review appeal, almost all states select an independent review organization (IRO) to evaluate cases.  In all states, the IROs’ reviewers are health care professionals who are board certified and have an expertise in the specialty under review and cannot have a conflict of interest that would impair their ability to perform an unbiased review.  Typically, external review laws also require that consumers exhaust all internal appeals processes before submitting a case for review.

[3] An individual must have had 18 months of prior continuous coverage (without a 63 day break); the most recent coverage must be through a group health plan; the individual may not be eligible for other coverage including Medicare or Medicaid; and must have exhausted COBRA coverage if eligible.


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