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Regulation and Compliance > Federal Regulation

PPACA: Agencies Postpone Claims and Appeals Enforcement

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Federal regulators expect to wait until Jan. 1, 2012, to enforce some of the new federal internal claims and appeals requirements.

The Employee Benefits Security Administration (EBSA), an arm of the U.S. Labor Department, has announced the 6-month extension of the enforcement grace period in Technical Release Number 2011-01.

The grace period affects implementation of Section 2719 of the Public Health PPACA ToolkitService Act. Congress added the section with a provision in the Patient Protection and Affordable Care Act (PPACA) that sets standards for internal claims and appeals and external reviews of coverage denials.

Although the technical release appears on the EBSA site, the grace period applies to enforcement actions by the U.S. Department of Health and Human Services (HHS), the U.S. Treasury Department, and HHS and Treasury Department agencies as well as actions by EBSA and the Labor Department.

The rules originally were set to take effect Sept. 23, 2010, but the agencies did not publish the interim final regulations that employers and health plans needed to start complying with Section 2719 until July 23, 2010.

The agencies announced in Technical Release Number 2010-02 that they would wait until July 1, 2011, to start enforcing parts of the regulations.

The agencies decided to extend a modified version of the original grace period because they want to revise the interim final regulations, based on comments they have received, and do not want to enforce standards that they intend to change in the near future, officials say.

The grace period extension affects a rule requiring plans to notify claimants about decisions on urgent care claims within 24 hours; a rule requiring plans to provide benefits notices in a “culturally and linguistically appropriate manner”; and a rule giving the definition of “substantial compliance” a plan must follow if it wants to require that a patient continue with the company’s own claim review process.

The grace period extension also affects a requirement that plans give the relevant diagnosis and treatment codes in denial notices.

Officials note that grandfathered plans are exempt from the rules.

Other internal and external appeals system coverage from National Underwriter Life & Health:


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