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CCH® BENEFITS — 09/28/10

DOL Provides Enforcement Grace Period For Certain Health Reform Claims And Appeals Standards

from Spencer’s Benefits Reports: In Technical Release No. 2010-2, the Department of Labor’s (DOL) Employee Benefits Security Administration (EBSA) has provided an enforcement grace period until July 1, 2011, for some of the new standards required under the Patient Protection and Affordable Act (ACA) for health care internal claims and appeals and external review. The enforcement grace period is in response to some group health plans and insurers’ requests for more time to change plan or policy procedures and to modify computer systems in order to comply with the new interim final claims regulations issued on July 23, 2010, and Aug. 23, 2010, to implement Public Health Service Act (PHSA) Sec. 2719.

PHSA Sec. 2719, as added by the Affordable Care Act, requires that group health plans and health insurance issuers maintain an effective internal claims and appeals process and external review.

Specifically, during the grace period, the DOL and the IRS will not take any enforcement action against a group health plan, and Health and Human Services (HHS) will not take any enforcement action against a self-funded nonfederal governmental health plan, that is working in good faith to implement the additional standards but that does not yet have them in place, with respect to the following standards:

• the timeframe for making urgent care claims decisions,
• providing notices in a culturally and linguistically appropriate manner,
• requiring broader content and specificity in notices, and
• substantial compliance failure and deeming the claimant to have exhausted the plan's or issuer’s internal claims and appeals process.

HHS also is encouraging states to provide similar grace periods to insurers and assures states that they will not be cited for failure to substantially enforce these provisions.

Questions regarding the provisions of this technical release may be directed to the EBSA Office of Health Plan Standards and Compliance Assistance at (202) 693-8335.

Model Notice Revised

EBSA also has released a revised version of its “Model Notice of Adverse Benefit Determination.” In August, EBSA first released a set of model notices to satisfy the disclosure requirements of the interim final regulations, including the notice of adverse benefit determination and notices of a final internal adverse benefit determination and a final external review decision.

The claims regulations had made changes to shorten the times for initial determinations with respect to urgent care claims, but did not make any changes to the times for making internal appeals decisions. The revised model notice makes clear that only the times for making the initial benefit determination were changed.

For more information, http://www.dol.gov/ebsa/IABDModelNotice2.doc.

For more information on this and related topics, consult the CCH Pension Plan Guide, CCH Employee Benefits Management, and Spencer's Benefits Reports.

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