<nobr>Aug 25, 2010</nobr>

Agencies Issue Further Guidance on PPACA Claims and Appeals

The Departments of Labor, Treasury, and Health and Human Services (HHS) on August 23 published a notice providing guidance to group health plans on compliance with the July 22 interim final regulation interpreting the Patient Protection and Affordable Care Act (PPACA) regarding internal claims and appeals and external review processes.

The preamble to this regulation specified that the Departments would address in "sub-regulatory" guidance how non-grandfathered self-insured plans could comply with the new federal external review process. The notice, along with Technical Release 2010-01, published by the Department of Labor, constitutes this "sub-regulatory" guidance.

In addition, the Departments published model notices for a notice of adverse benefit determination, a notice of final internal adverse benefit determination, and a notice of final external review decision.

The agencies also note that model language for the description of the internal claims and appeals and external review procedures in the summary plan description will be posted in the future on the websites of DOL ( http://www.dol.gov/ebsa ) and HHS's Office of Consumer Information and Insurance Oversight ( http://www.hhs.gov/ociio/ ). Lastly, they noted that HHS will be providing further information in the future on an interim enforcement safe harbor for fully insured group health plans.

Technical Release 2010-01 (TR): The PPACA rules on claims and appeals procedures apply to non-grandfathered self-insured plans for plan years beginning on or after September 23, 2010. The TR provides an interim enforcement safe harbor for these plans with respect to the federal external appeals process for a period beginning with the PPACA effective date and until superseded by future guidance. During this period, a self-insured group health plan can choose to comply either with the procedures outlined in the TR or with State external review processes (for those States that choose to expand access). If a self-insured group health plan adheres to either of these compliance methods, the DOL and the IRS will not take any enforcement action against the plan, and the plan will not be subject to excise tax liability.

TR Procedures: The TR procedures are based on the NAIC Model Act in place on July 23, 2010, except that they do not include all the consumer protections of that Act. The TR provides for two types of reviews: a standard review and an expedited review. Both procedures provide rules for the length of time for a claimant to file a request for external review, the time frames for various kinds of reviews and notices, and the referral to an Independent Review Organization (IRO).

The TR notes that in the case of both the standard and expedited review, the IRO will review the claim de novo and is not "bound by any decisions or conclusions reached during the plan's internal claims and appeals process." The TR also notes that if an external review reverses a plan's decision, the plan must immediately provide coverage or payment for the claim.

Questions or comments on this issue should be addressed to Gretchen Young (gyoung@eric.org).

Websites:

Technical Release 2010-01

Notice on Availability of Interim Procedures

Model Notice of Final Internal Adverse Benefit Determination

Model Notice of Adverse Benefit Determination

Model Notice of Final External Review Decision

Interim Final Rule

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