The Departments of Health and Human Services (HHS), Labor, and the Treasury (the Departments) have issued an amendment to the interim final regulations implementing the requirements regarding internal claims and appeals and external review processes for group health plans and health insurance coverage in the group and individual markets under provisions of the Affordable Care Act.

Background 

The Affordable Care Act generally requires group health plans and health insurance issuers to implement an effective internal and external appeals process for coverage determinations and claims. The appeals provision applies to all health plans created or purchased after March 23, 2010, and affects each plan as that plan starts a new plan year or policy year on or after September 23, 2010. These requirements do not apply to grandfathered health plans.  

The Departments have been issuing regulations in several phases to implement the standards for plans and issuers regarding both internal claims and appeals process and external review. Original interim final regulations were issued by the Departments on July 23, 2010, followed by a series of technical guidance further explaining certain requirements.

Amendment to Interim Final Regulations 

According to the amendment to the interim final regulations, the revised rules are intended to respond to feedback from a wide range of stakeholders on the original interim final regulations and to assist plans and issuers in coming into full compliance with the law through an orderly and expeditious implementation process.

The amendment to the interim final regulations makes several changes to the original rules, including:

  • The timing of notification required in the case of urgent care claims and information required to be included in notices of adverse benefit determinations, with respect to internal claims and appeals;
  • The scope of claims eligible for the federal external review process, narrowed to only those claims that involve medical judgment (as determined by the external reviewer) or a rescission of coverage; and
  • An extension of the transition period during which a state external review process will be treated as meeting the minimum standards required under the law, through December 31, 2011.

Technical Release 2011-02, issued contemporaneously with the amendment, also establishes a set of temporary standards for certain group health plans and issuers in states whose external review processes do not meet the requirements of the law. Under the temporary standards, claimants must have at least 60 days to file for external review after receiving notice of an internal adverse benefit determination.

  • These temporary standards will apply until January 1, 2014. Beginning January 1, 2014, a state external review process will need to satisfy the law's requirements, or the issuer (or plan) will become subject to a federally-administered external review process.

The amendment to the interim final regulations is effective as of July 22, 2011.

Additional Information 

For more information on internal claims and appeals and external review processes, please click on the links below. To read more about the Affordable Care Act, please visit the HR360 section on Health Care Reform.

Topics: Health Care Reform

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