CSI Benefits Industry News

You’ve likely been focusing mostly on the plan design and administration requirements of health care reform. But, the law has a series of new notification and communication requirements that start this year and extend over the next several years.

You’ll need to be thinking not only about the strategic communication needs—how to keep employees engaged in their health and managing costs—but also how to meet these legal requirements in a way that adds the most value. (And, creates the least amount of additional work for you and your team.)

Much is still in flux about the changes in health care, but this article captures the key notification requirements and what to look for as regulations are issued.

Seven health care reform notices

The final regulations detailing the exact disclosure requirements for all regulations are not yet out. But here are seven items that should be on your radar for your benefits communication strategy.

• Notice of key plan design changes effective 1/1/11 (during this fall’s enrollment for most companies)
• Summary of material changes (2012)
• Summary of medical coverage (2012)
• Description of all disease management programs (2012)
• Automatic medical enrollment and opt-out actions (TBD—likely 2013)
• Notification of exchanges and “free choice vouchers” (2013)
• Description of claims process (TBD)

Read more…..

Employee Benefit News article used by permission

The Obama Administration released interim final regulations aimed at creating a system of checks and balances for the internal and external appeals processes of health claims.

Governed by the Patient Protection and Affordable Care Act, the interim final rule requires group health plans and insurers to establish a comprehensive appeals process for patients who appeal decisions on coverage, services and claim payments. The interim final regulations apply to self-funded health plans, but not to grandfathered plans under the PPACA.

The Departments of Health and Human Services, Labor and the Treasury issued the interim final rule, which will take effect on Sept. 21, 2010.

Health plans and insurers that are subjected to the regulations are required to establish an internal appeals process that:

• Allows consumers to appeal when a health plan denies a claim for a covered service or rescinds coverage;

• Gives consumers detailed information about the grounds for the denial of claims or coverage;

• Requires plans to notify consumers about their right to appeal and instructs them on how to begin the appeals process;

• Ensures a full and fair review of the denial; and

• Provides consumers with an expedited appeals process in urgent cases.

If a health plan or insurer denies the appeals case, the patient, under the regulations, can present his or her case to an independent reviewer not affiliated with the health plan or insurer.

Most states provide an external appeals process in which a second set of eyes reviews the case. However, state laws on external appeals of health claims can vary greatly depending on the state. As a result, the interim final rule calls for a federal standard for external reviews of claim appeals cases.

For external appeals, federal regulators are encouraging states to adopt the guidelines created by the National Association of Insurance Commissioners. The interim final rule calls for states to implement the NAIC standards before July 1, 2011. The NAIC rules require:

• External review of plan decisions to deny coverage for care based on medical necessity, appropriateness, health care setting, level of care, or effectiveness of a covered benefit.

• Clear information for consumers about their right to both internal and external appeals – both in the standard plan materials and at the time the company denies a claim.

• Expedited access to external review in some cases – including emergency situations or cases where their health plan did not follow the rules in the internal appeal.

• Health plans must pay the cost of the external appeal under State law, and States may not require consumers to pay more than a nominal fee.

• Review by an independent body assigned by the State. The State must also ensure that the reviewers meet certain standards, keep written records, and are not affected by conflicts of interest.

• Emergency processes for urgent claims, and a process for experimental or investigational treatment.

• Final decisions must be binding so, if the consumer wins, the health plan is expected to pay for the benefit that was previously denied.

Source: Employee Benefits News article used by permission

Federal regulators released interim final rules implementing a new Patient’s Bill of Rights under the Patient Protection and Affordable Care Act. The guidance addresses preexisting condition exclusions, retroactive rescissions, lifetime limits and annual dollar limits.

“These rules effectively put in place a basic set of consumer protections known over the years as the ‘Patient’s Bill of Rights.’ This is a concept introduced 15 years ago and supported by both Democrats and Republicans,” said Secretary of Health and Human Services Kathleen Sebelius in an e-mail statement.

The Federal Register will publish the rules on June 28. The new regulations, issued by the Departments of Health and Human Services, Labor and Treasury, will take effect for most plans on or after Sept. 23. For calendar year plans, the rules will take effect Jan. 1, 2011.

The interim final rules, which are nearly 200 pages, focus on PPACA provisions that apply to all health plans, including grandfathered health plans. According to consultants at Hewitt Associates, the provisions in the interim final rules adopt the following:

Preexisting condition exclusions: Prohibits preexisting condition exclusions for both benefit limitations and coverage.

Retroactive rescissions: Prohibits retroactive rescissions of coverage except in cases of fraud or an intentional misrepresentation of material facts, with no exception. Insurers and plans are required to provide at least 30 days advance notice of a rescission with time to appeal.

Lifetime limits: Prohibits lifetime limits on the dollar value of “essential health benefits” for any individual participating in a group health plan or group health insurance coverage. Additional notice and enrollment opportunity rules apply for individuals whose coverage or benefits ended by reason of reaching a lifetime limit.

Annual dollar limits: Restricts annual dollar limits on “essential health benefits” to no less than $750,000 beginning Sept. 23, 2010, $1.25 million beginning Sept. 23, 2011, and $2 million beginning Sept. 23, 2012 but before Jan. 1, 2014. Good faith compliance with a “reasonable interpretation” of what is an essential health benefit will be allowed until regulations defining that term are issued.

“The interim final rule allows group health plans or health insurance coverage that has an annual dollar limit on benefits below the restricted annual limits permitted, such as limited benefit plans, to seek a waiver to delay compliance with the rules on restricted annual limits if the plan can prove that its current annual limits are necessary to prevent a significant loss of coverage or increase in premiums,” Hewitt experts note. “The restriction on annual limits does not apply to health flexible spending arrangements, medical savings accounts or health savings accounts.”

The guidance also clarifies that the annual limit restriction does not apply to health reimbursement arrangements that are integrated with a group health plan that meets the requirements under health care reform or to stand-alone retiree-only HRAs.

The rules also provide consumer-protection mandates that apply to non-grandfathered plans, including:

• Prohibiting group health plans or health insurance issuers from requiring a referral for OB-GYN care or from allowing a pediatrician to be a designated primary care provider;
• Prohibiting prior approval for emergency care or higher cost-sharing amounts for out-of-network emergency care; and
• Requiring a “reasonable” reimbursement for providers of out-of-network emergency care before balance billing is allowed.

Source: Employee Benefits News article used by permission

Tuesday, April 13, 2010

1:00 p.m. – 2:00 p.m. EST

The recent passage of the Patient Protection and Affordable Care Act and the Health Care & Education Affordability Reconciliation Act affects nearly every American and will reshape approximately one-sixth of the national economy. Under this new legislation, Americans for the first time will be required to purchase health insurance, and will face penalties if they fail or refuse to do so. Additionally, employers for the first time will be required to offer their workers health insurance coverage, and those that don’t will face fines and penalties. In this one-hour webinar, we will provide an up-to-the minute clear and complete review of Health Care Reform’s main requirements as well as a practical discussion of what it means to employers.

Why Should You Attend This Webinar? Understanding and interpreting the new sweeping healthcare reform changes is now a top priority for all employers, and you have likely been inundated with invitations from your lawyers and other vendors to participate in their Health Care Reform-related events. To help clients work through the myriad of issues and changes, we established an interdisciplinary Health Care Reform Task Force comprised of Benefits, Tax, Health Care and Labor lawyers in mid-2009 to focus on the new law and how it will affect our clients. During the webinar, we will share our collective insights, clarify common misconceptions about the new law, and highlight the instances in which the law fails to provide clear guidance. We will also help you to anticipate what the final rules might look like once they are released by the government. By participating, you will reap the benefits of our months of learning on this critical topic.

Speakers:

Peter J. Marathas, Jr., Partner, Proskauer

James R. Napoli, Senior Counsel, Proskauer

Registration:

Please follow these steps to register for the webinar:

Go to: https://university.learnlive.com/proskaueronlineevents.

If you are a first time user, create a new account by clicking the “New User Registration” button and completing the New User Registration fields. The Company Pass Code is 9736529. If you are a returning user, login with your existing account information.

Click the “Submit” button.

This will bring you to the Catalog page.

Click the “Enroll” button next to the webcast titled Update on National Health Care Reform

You will receive a reminder 24-hours prior to the webinar with login instructions. For technical assistance with registration, please call 206-812-4700.

There is no fee for this seminar.

CLE:

In accordance with the requirements of the New York State Continuing Legal Education Board, this non-transitional continuing legal education program is not approved for newly admitted attorneys within the first two years of admission to the Bar. It is approved for experienced attorneys, for a maximum of 1 credit hour in the area of Professional Practice. In order to receive CLE credit for the webinar you are required to click all of the participation pop-ups that will appear throughout the program.

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It is time to scrap the current bill and come up with a true bipartisan bill that is based on the free market and not government take over of the entire system. Admittedly, there are major issues but government take over is not the solution.