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Appeals process for non-grandfathered plans
As you know, the health care reform law includes requirements for internal claims and appeals, and external reviews for fully insured and self-funded non-grandfathered plans. The law says that a plan must, at a minimum:
- Have an internal claims and appeals process.
- Provide notice of an external appeals process.
- Allow an enrollee to review his or her file, present evidence during the appeals process and continue to receive coverage pending outcome.
- Implement an external review process.
A recent interim final rule offers more information. Key points include:
- The rule applies to individual plans and fully insured and self-funded group plans
- The rule does not apply to any grandfathered plans.
- Plans must follow state or federal appeals processes.
- A benefit determination subject to internal review includes:
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Whether a service is a covered benefit.
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Imposition of pre-existing condition or other benefit limits.
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Medical necessity and experimental treatment determinations.
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A determination to rescind coverage.
- Plans must ensure that internal review processes are fair and impartial.
- Individuals must be notified of their rights to internal reviews and external appeals in a "culturally and linguistically appropriate manner."
- Consumer protections for the external review process are required for certain benefit determinations and decisions to rescind coverage.
- For plan years before July 1, 2011, insurers in states with an existing external review process that complies with health care reform may follow that process. If the state external review process does not comply, or if there is no applicable state external review process, the federal standard (not yet published) must be followed. For self-insured plans, unless the state external review process applies, the federal standard (not yet published) must be followed.
- All non-grandfathered fully insured and self-funded group health plans must meet the new consumer protection standards for internal and external review for plan years on and after September 23, 2010.
More regulations will be issued for internal claims and appeals process, as well as additional guidance for external reviews. We'll keep you posted as this information becomes available. As always, talk with your sales representative with any questions.
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