Unfinished Business: The Affordable Care Act and the Problem of Delayed and Denied ERISA Healthcare Claims
34 Pages Posted: 22 Mar 2014 Last revised: 7 Apr 2014
Date Written: 2014
The Affordable Care Act (ACA) grew out of a longstanding desire to bring universal healthcare coverage to Americans. But universal healthcare was not the only goal. Some longed to see ERISA’s preemption of state-law remedies softened, so that healthcare claims in ERISA plans could no longer be delayed and denied with impunity. While the ACA now extends coverage to more Americans, ERISA preemption remains unchanged. So, when ERISA healthcare plans — which insure most Americans — improperly delay or deny healthcare claims, the plans still risk nothing more than the eventual payment of that claim’s value.
This article posits that ERISA claims processing and preemption reform is the unfinished business of the ACA — without it, the consumer remains consistently disadvantaged by both the process and substance of healthcare claims processing. Substantively, the ACA leaves ERISA preemption intact so that plan participants with denied claims must work tirelessly and with exacting attention to detail in order to appeal and eventually win back — at most — the value of the denied or delayed claim. Without further changes to the claims process and ultimately, to ERISA preemption, the ACA includes more people in health plans but also leaves them vulnerable to the vagaries of health plan decision-makers. The promise of universal, meaningful healthcare coverage therefore remains incomplete.
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