Viewing posts from: July 2010

The Affordable Care Act: Internal & External Appeals for Patients

Posted July 26, 2010 by admin

On July 23, 2010, Interim Final Rules relating to Internal Claims and Appeals and External Review Processes under PPACA and HCEARA were issued by the Departments of Health and Human Services (HHS), Labor (DOL), and the Treasury (IRS). These requirements do not apply to Grandfathered plans.

Group health plans (and health insurance issuers) need to establish internal and external review processes for “adverse benefit determinations.” For internal claims and appeals processes, group health plans must comply with existing ERISA claims procedure regulation and with six (6) new requirements. (more…)

Health Reform Rules Regarding Preventive Care and Cost-Sharing

Posted July 15, 2010 by admin

Clarification from HHS/DOL/Treasury: Health Reform Rules Regarding Preventive Care and Cost-Sharing

The Departments of Health and Human Services (HHS), Labor (DOL), and the Treasury issued new regulations today, requiring new private health plans to cover evidence-based preventive services and eliminate cost sharing requirements for such services. The agencies have concluded that cost sharing, including deductibles, coinsurance, or copayments, has been found to reduce the likelihood that preventive services will be used.

Under these new regulations, non-grandfathered plans, beginning with the first plan year on or after 09/23/2010, must cover preventive services that have strong scientific evidence of their health benefits, and these plans may no longer charge a patient a copayment, coinsurance or deductible for these services when they are delivered by a network provider (out-of-network claims can be subject to these cost-sharing measures). Grandfathered plans—those plans that do not, for example, ever increase coinsurance requirements or boost employee premium contributions by more than five percentage points are exempt from the mandate to provide full coverage for preventive services. Also, any treatment that results from a preventive service can be subject to cost-sharing requirements (if the treatment is not itself, a recommended preventive service).

(more…)

New Compliance Chronicles Article Posted – DOL Model Notices

Posted July 2, 2010 by admin

A new article discussing the Department of Labor’s issuance of model notices has been posted in the Compliance Chronicles section of the Crawford Advisors, LLC website.

The article states,

“The DOL provided three model notices for some of the health care reforms that will take effect for a plan’s first plan year after 09/23/2010. Each notice includes background information regarding the provision’s requirements, followed by suggested DOL language that plan sponsors can utilize to satisfy their notice obligations…”

For more information, and to sign up to receive Crawford Advisors’ Compliance Chronicles updates, enter your email address in the Compliance Chronicles box on the right hand side of this website.

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