It would have been better had the media left out the empty quotes and concentrated on what was a glaring omission in most of their stories—why people file grievances in the first place. The White House fact sheet says consumers can use the review procedure if an insurer has rescinded their policies. But if rescissions will be outlawed, what’s the big deal? A major reason people file grievances is over the question of medical necessity—whether a proposed treatment is really therapeutic, and whether it’s covered by the policy. Under current state arrangements, disputes must usually involve medical necessity, and not every state allows appeals for experimental treatments. Good stories might have looked at what kinds of treatments are denied, and why, and explored why policies may or may not cover them—in other words, might have given consumers some real guidance.
What rights do the new regulations give consumers in these matters? The language in the regulations of the National Association of Insurance Commissioners which sets the new standards is fuzzy says a state insurance official. It does not provide a clear definition of what is experimental. “I am not seeing a definition of medically necessity either,” he told me. “The federal regulations are all about process, not substance.” The substance of a dispute is governed by the health plan’s requirements for medical necessity, appropriateness, and effectiveness of a covered benefit.
So it seems that there is far more to the story than the media or the White House has told. Consumers may have the same problems getting redress they’ve always had, and making sure they get a clear reason for the denial (which the rules provide) is not the same. Disputes over medical necessity will no doubt continue. Local reporters, not Washington types, should take it from here.