Under the Affordable Care Act (ACA), millions of consumers will use state-based Health Insurance Exchanges to enroll in coverage—an estimated 1 million will enroll in NY’s Exchange alone.  Adopting a robust system of consumer protections will be pivotal to the success of these Exchanges.

A new report from the Community Service Society of NY, featured in today’s Crain’s Health Pulse, uses the enrollment experiences of two example families to identify how a user-friendly Exchange should work. These scenarios reveal the problem that consumers potentially face three dueling appeals as their eligibility for premium tax credits and Medicaid is processed by an Exchange:  (1) a state-based Exchange appeal; (2) a Medicaid Fair Hearing; and (3) a federal appeal under Section 1441 of the ACA.

The report makes a series of recommendations that will reduce the need for appeals in the first place by building strong upfront consumer protections in the Exchange and concludes with recommendations for designing a streamlined appeals mechanism.

It is unclear how the appeals process will be decided for New York. The first proposed Exchange regulations from the U.S. Department of Health and Human Services (HHS) told state Exchanges to design their own appeals processes. In the final regulations, HHS said THEY would be issuing appeals guidance instead. To date, no guidance on appeals has been issued. And so we wait…