July 23, 2010 – Internal Claims and Appeals and External Review Process Regulations – No Major Medical Plan Goes Untouched!
Today, Federal agencies published interim regulations under the Internal Revenue Code, Employee Retirement Income Security Act of 1974 (“ERISA”), and the Public Health Services Act (“PHSA”) implementing the provision of the Patient Protection and Affordable Care Act (“PPACA”) addressing health plan appeals and external reviews. A copy of the regulations is available at: http://edocket.access.gpo.gov/2010/pdf/2010-18043.pdf. Additional information regarding the new rules is available at http://www.hhs.gov/ociio/regulations/consumerappeals/index.html.
The regulations impact group health plans (insured and self-insured) subject to the portability requirements of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). In other words, stand alone dental plans, stand alone vision plans, many health FSAs, most specified disease and fixed indemnity policies, and other HIPAA excepted benefits are not impacted. The regulations also do not impact grandfathered plans.
The regulations enhance internal claims and appeal processes, building upon the requirements of the DOL claims regulations. Six new requirements are added. And, the regulations provide for additional external review (either at the state level or federal level) for all plans, regardless of whether the plan is insured or self-insured. [Details of the federal external review process will be released later.]
The requirements are effective for the first plan year beginning on or after September 23, 2010; for calendar year plan years, this is January 1, 2011.
The regulations require:
- Review and, in almost all cases, amendment of the plan document.
- Changes to communications materials (e.g., SPD, summary, notices, etc.).
- Changes to claims processing systems.
For a good summary of the regulations, see the Preamble, SUPPLEMENTARY INFORMATION, II. Overview of the Regulations, at pages 43332 through 43337.
Please contact us if you have any questions regarding the regulations or the application of the rules to your plan.