February 2011 Health Care Reform Insights, "Guidance on Non-Grandfathered Plans’ Claims and Appeals Procedure Required by the Affordable Care Act"
Note: In March 2011, the Department of Labor extended the non-enforcement grace period applicable to the requirements described in the “Changes to Internal Claims and Appeals Rules Affected by the Enforcement Grace Period” section on page 2 of this publication. In general (but not uniformly), the grace period now runs until the first plan year on or after January 1, 2012. For details about this news, refer to Segal’s March 31, 2011 Capital Checkup.
The Affordable Care Act (the abbreviated name for the Patient Protection and Affordable Care Act) requires non-grandfathered group health plans revise their internal appeals process and to adopt a new external appeals procedure. Non-grandfathered plans are those that were not in existence as of March 23, 2010, the date of enactment, as well as plans that lose their grandfathered status due to plan changes. The new procedures apply to all non-grandfathered group health plans, including self-insured plans and governmental plans.
The Departments of Health and Human Services, Labor and Treasury have published Interim Final Rules governing those internal and external appeals procedures. In addition, to assist self-insured plans in adopting an external appeals procedure, the Department of Labor issued Technical Release 2010-01, which provides guidance on an interim federal external review process for self-insured group health plans.
This issue of Health Care Reform Insights summarizes the rules, which will require significant changes in appeals procedures. The issue concludes with lists of action steps, including what non-grandfathered group health plan must do to comply with the new internal claims and appeals procedures and what they must do to implement the new external review appeal rules.