(As touched on later, ERISA bars states from regulating private-sector employee health plans but allows them to regulate many functions performed by insurers and managed care organizations serving ERISA plans.) The discussion also will consider how to enhance consumer protections without blunting plan sponsors’ ability to contain costs. Taking into account what other states have done, the meeting also will explore key issues facing federal policymakers currently attempting to reconstruct and integrate the elements of the grievance, appeals, and legal processes available to consumers under the Employee Retirement Income Security Act of 1974 (ERISA), which governs about 2.5 million private-sector employee health plans. This Forum session will explore the experience of two existing models for reviewing managed care plan decisions, one used by the Medicare program and another by the state of Florida. While there is great variation in the reform proposals and disagreement about how much consumers might be hurt by the current limitations of their appeal and legal options, a pivotal issue is whether patients disputing health plan denials of medical treatment or coverage should have access to independent, external review of plan decisions. Some of these would alter or establish internal health plan grievance procedures, impose external review of plan decisions, and provide greater access to court remedies for plan members. Spurred by consumer reaction to some managed care practices, provider attempts to improve their bargaining position with purchasers, and a flurry of state legislation that might conflict with federal law, Congress and the executive branch are considering a continuum of controversial proposals. ![]() Federal policymakers face growing pressure from several quarters to bolster consumer protections available to the 125 million people in private-sector employee health plans.
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