Posts Categorized: Affordable Care Act

The Next Generation of Appeal Procedures

in Affordable Care Act

On Monday, the DOL released additional rules with respect to the Federal external appeal procedures.  These procedures apply to non-grandfathered self-insured health plans.  The procedures include a number of issues for plans and plan sponsors, and unfortunately there is little time to manage them. Calendar year plans will have until January 1, 2011 to accomplish the following – The rules require the plan to process external appeals, send notices to participants and send the appeal to an appropriate IRO. Presumably, a plan can contract with their existing TPAs to perform these actions, but TPAs will need to be contacted, procedures will… Continue Reading

Significant Changes for Appeal Rules and EOBs

in Affordable Care Act

Previously, on July 23, 2010, DOL, HHS and Treasury issued interim final rules regarding the claim and appeal requirements under the Affordable Care Act.  These new requirements will apply to all non-grandfathered plans beginning January 1, 2011 (for calendar year plans).  Yesterday, DOL updated the rules by releasing two additional pieces of guidance – new Federal external appeal rules for self-insured plans and model notices for all plans. The Federal external appeal rules are contained in Technical Release 2010-01 and require self-insured plans to follow a new mandatory external appeal process, once participants complete the internal claim and appeal process. DOL also issued three model notices… Continue Reading

Mini-Med Waiver Program

in Affordable Care Act

Under the current interim final rules issued June 28, 2010, most mini-med plans would violate the lifetime and annual limit requirements beginning the first plan year on or after September 23, 2010 (or January 1, 2011 for calendar year plans). This means that most mini-med plans would cease to exist under the new requirements. However, in the preamble to the interim final rules, HHS indicated that it will start a temporary waiver program, so that mini-meds could apply for a waiver from the lifetime and annual limit requirements. If the waiver is approved, the mini-med plan would be exempt from… Continue Reading

Michelle’s Law is Still Alive (Barely)

in Affordable Care Act, Health Benefits

As noted in our August 17th post, many sponsors are applying the age 26 regulations to children as defined in IRC Section 152(f)(1). This means that other children, such as children of a legal guardian, children of a domestic partner or grandchildren, would not be covered by the mandatory age 26 rules. Thus, applicable plans could apply the usual dependency tests to these children as they have in the past (e.g., age 19 and age 25 if a full time student).   If a plan sponsor did apply full-time student rules to children not covered by the age 26 regulations, then Michelle’s Law would still apply to those children…. Continue Reading

Texas Injury Plans

in Affordable Care Act, HIPAA Privacy & Security, Welfare Benefits

Under Texas law, employers can opt-out of the normal workers’ compensation system by sponsoring a separate, self-insured plan for workplace injuries, typically referred to as a Texas Injury Plan. Texas Injury Plans are treated as ERISA group health plans and subject to the typical ERISA requirements, as well as the HIPAA privacy rules. Recently, some third-party administrators and plan sponsors have begun to review whether these types of plans are covered by the Affordable Care Act, and whether an exception can apply. There are exceptions in ERISA and the Internal Revenue Code for “worker’s compensation and similar insurance” benefits. However, when an employer opts… Continue Reading