Author: Sam Fish | Posted: 26. July 2010 09:23

On July 23, 2010, the U.S. Department of the Treasury, Department of Labor, and Department of Health and Human Services issued in the Federal Register for that date (Volume 75, No. 141, page 43330) Interim Final Rules for group health plans and health insurance issuers relative to internal claims and appeals and external review processes to implement requirements contained in the Patient Protection and Affordable Care Act (P.L. 111-148). 

The rules generally apply to group health plans and group health insurance issuers for plan years beginning on or after September 23, 2010.  These requirements do not apply to grandfathered health plans under section 1251 of the Affordable Care Act.  For plans and issuers subject to existing state external review processes, these regulations include a transition period until July 1, 2011.  During this period, the state process applies and the federal departments will work individually with the states on an ongoing basis to assist in making any necessary changes to incorporate additional consumer protections so that the state process will continue to apply after the end of the transition period.  If there is no state process, the federal process will apply beginning on or after September 22, 2010. 

The rules contain new criteria to avoid conflict of interest and there must be continual coverage pending the outcome of an internal appeal.  The process and protections of the group health coverage standards are also pertinent to the individual health insurance market.  For a state external review process to apply instead of the federal external review process, the Affordable Care Act provides that the state external review process must include, at a minimum, the consumer protections of the NAIC (National Association of Insurance Commissioners) Uniform Model Act.

About Sam Fish

Sam Fish has over 40 years of legal experience in federal and state human services laws and programs, having joined PCG in 1995 after serving as Chief Counsel, Region I, for the U.S. Department of Health and Human Services for more than 25 years. At PCG, Sam provides legal advice and counsel and has served on many projects that required legal research and interpretation and implementation of many federal and state laws. He has also participated in in-house training in new litigation areas, including Temporary Assistance for Needy Families (TANF), the Balanced Budget Act (BBA), and the Health Insurance Portability and Accountability Act of 1996 (HIPAA). He is available for legal guidance in program areas including school-based billing, third-party liability, Olmstead implementation, and Medicare and Medicaid reimbursement. Currently, he is providing guidance and counsel in the interpretation and implementation of the new health care legislation.

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