May 21, 2015
In March of 2010, Congress passed the Affordable Care Act and signed by President Obama. It created a new program – the Pre-Existing Condition Insurance Plan (PCIP) program-- to make health insurance available to Americans, which have been denied coverage by private insurance companies because of a pre-existing condition. This coverage is for people living with such conditions as diabetes, asthma, cancer, and HIV/AIDS. Often insurance has often been priced out of the reach of most Americans who buy their own insurance, and this has resulted in a denial of coverage for millions. The Pre-Existing Condition Insurance Plan is designed to address these challenges by offering comprehensive coverage at a reasonable cost.
In the case of John Q Public, he Affordable Care Act puts him charge of his health care. He is protected by the “Patient’s Bill of Rights” which Provides Coverage for Pre-existing Conditions. John is eligible for health coverage under the Pre-Existing Condition Insurance Plan.
North Carolina is a state that runs it own PCIP, which is called Inclusive Health: State Option. To qualify for coverage in North Carolina, John must meet certain eligibility requirements. He must be a citizen or national of the United States or residing in the United States legally and a North Carolina resident; must have been uninsured for at least the last six months before he applies and/or, must have a pre-existing condition or been denied coverage because of his health condition. Because John has diabetes, it is a Presumptive Condition (having medical conditions, presumed to be uninsurable) he is automatically eligible for Inclusive Health in NC.
If, John is denied coverage for his pre existing diabetes, he may appeal that decision. To request an appeal, complete an Internal Appeal Request Form. John should write a very clear and simple letter providing the facts and a concise explanation of why he believes his coverage to be denied. He should keep detailed records of all interactions, including names of representatives you speak with on the phone and relevant dates. Keep copies of claims and bills, appeal letters and any attachments, and any other relevant communications. John should always follow-up.
Should John’s appeal be denied, John should go to the next level of appeals. This does not happen automatically and it has to be communicated that he has desire for a second level, or External Review. This will be a re-consideration of his original claim by professionals with no connection to his insurance plan. If the external reviewers think he should be cover, he must cover it. To understand Administrative Law, it is important to understand the difference between a statue and a regulation. A statute is an enactment of a legislative body (federal, state, county or city); generally referred to as a law. The federal statutes are contained in the United States Code, or U.S.C. A regulation can be issued by an agency or department, such as the Health and Human Services to carry out law intended by Congress. Federal regulations are compiled in the Code of Federal Regulations, or CFR.
Administrative law is the body of law that allows for the creation of public regulatory agencies and contains all of the statutes, judicial decisions, and regulations that govern them. Administrative law is created by administrative agencies to implement their powers and duties in the form of rules, regulations, orders, and decisions. Administrative procedure constitutes the methods and processes before administrative agencies, as distinguished from judicial procedure, which applies to courts.
The fundamental challenge of administrative law is in designing a system of checks that will minimize the risks of bureaucratic arbitrariness and exceeding your limits, while safeguarding for the agencies the suppleness that they need in order to act