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On July 23, 2010, the government published rules implementing new internal claims and appeals and external review processes under health care reform. The rules are effective for plan or policy years beginning on or after September 23, 2010, although the rules do not apply to grandfathered plans.
The rules address new requirements for state external review processes that apply mainly to fully insured group health policies and individual insurance contracts. They also address new requirements for federal external review processes that apply to self-funded group health plans.
New External Review Process
For self-funded group health plans, a new federal external review process will generally apply. The federal review process will not include reviews of adverse benefit determinations involving failure to meet the eligibility requirements of a plan. The process will be similar to the process set forth in the NAIC Uniform Model Act and will meet standards issued by the government, including standards describing:
Expedited reviews will be available for claimants whose life or health would be seriously jeopardized by following the normal process and timeframes. Special standards require additional consumer protections to ensure that adequate clinical and scientific experience and protocols are taken into account for external reviews involving experimental or investigational treatments.
These regulations do not, however, address the specifics of the new standards. Instead, the regulations provide that the agencies will be issuing sub-regulatory guidance on how non-grandfathered self-funded group health plans may bring their existing internal appeal processes into compliance with the requirements of the new federal external review process in the very near future.
New Internal Claim and Appeal Process Requirements
The regulations also address internal claim and appeal process requirements. In addition to complying with existing Department of Labor claims regulations, self-funded group health plans must follow six new requirements:
New Requirement Regarding Coverage During Internal Appeal
In addition to these six new requirements, the regulations implement a new statutory requirement that a plan must provide continued coverage pending the outcome of an internal appeal. For this reason, individuals in urgent care situations and individuals receiving an ongoing course of treatment may be allowed to proceed with expedited external review at the same time as the internal appeals process.
Rules Effective for Plan Years Beginning on or After September 23
Since the new claims and appeal rules are effective for non-grandfathered, self-funded group health plans in plan years beginning on or after September 23, 2010, plans sponsors have little time to comply. Plan sponsors should promptly begin reviewing their internal claims process to ensure it meets the new requirements. They should also continue to watch for the model notices and additional external review guidance that are expected soon.
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