Health Care Reform's interim claims appeals regulations amended

The IRS issued amendments to the interim final regulations regarding internal claims and appeals and external review processes for group health plans and insurers.  Recall that the government had previously extended the non-enforcement period as noted in our ErisaALERT Health Care Reform Update Part III.  The term group health plans includes both insured and self-insured group health plans and does not apply to grandfathered plans.  Here are the highlights:

·         The time frame for deciding urgent care claims is back to 72 hours with the proviso that    urgent care claims be decided as quickly as possible but in no event later than 72 hours

·         The requirement for including diagnosis and treatment codes in notices of adverse benefit determination has been removed and a requirement to provide this information upon request has been added.

·         The threshold for providing denial notices in non-English language has been changed to 10% or more of the population residing in the claimant’s county.  The government will update data on its website periodically regarding this information.  If the threshold is met, the notice must include a one sentence statement in the relevant non-English language about the availability of language services. In addition to the one sentence requirement, the plan or insurance company must provide a customer assistance process with oral language services in the non-English language and provide written notices in the non-English language upon request.

·         The transition period for states to implement external review processes has been extended to December 31, 2011.

·         The scope of claims for which external review has not been initiated before September 20, 2011 is narrowed to claims that involve medical judgment or a rescission of coverage.

·         A plan may not delay payment because the plan disagrees and intends to seek judicial review.

The amendments, revised notices and other information can be found on EBSA’s website

IRS seeking comments on comparative research fee

The Affordable Care Act established the Patient-Centered Outcomes Research Institute and provided that the institute be funded by the Patient-Centered Outcomes Research Trust Fund.  The Trust Fund is to be funded in part by fees to be paid by issuers of health insurance policies and sponsors of self-insured health plans. IRS Notice 2011-35 requests comments regarding how the fees to fund the institute should be calculated and paid, including several possible rules and safe harbors.

Section 6301 of the Affordable Care Act added sections to the IRC which impose fees on “specified health insurance policies” and “applicable self-insured health plans” based on the average number of lives covered under the policy or plan. The fees are effective for policy and plan years ending after September 30, 2012.

The Notice does not provide guidance but describes potential guidance that is expected to be proposed to implement the fees and seeks comments on the potential guidance.   

Comments must be submitted in writing by September 6, 2011.

IRS issues the 2009 Form 8955-SSA and extends filing due date

The IRS has issued the 2009 Form 8955-SSA and extended the due date for the 2009 and 2010 Form 8955-SSA to the later of January 17, 2012 or the due date that generally applies for filing the 2010 Form 8955-SSA.  The 2010 Form 8955-SSA has not been issued. The January 17, 2012 due date may not be extended by filing a Form 5558.

The Form 8955-SSA is used to report information about separated participants with deferred vested benefits.  The IRC imposes a penalty for failure to file of $1 for each participant not reported  multiplied by the number of days the failure continues to a maximum penalty of $5,000.

It is important to keep in mind that the plan administrator must provide an individual statement to each affected participant. A penalty of $50 is imposed on the person required to furnish the statement to each affected participant for each willful failure to furnish the statement or a willful furnishing of a false statement.

CMS update Medicare Part D creditable coverage notices

CMS revised the Medicare Part D creditable coverage notices and changed the date for delivering the notice to October 15^th (from November 15^th).  Group health plans that offer prescription coverage to Medicare eligible participants must provide Part D creditable coverage notices

• Before the beginning of Medicare Part D annual enrollment period
• Before an individual is first eligible for Medicare Part D
• Before the effective date of coverage for any Medicare eligible individual that joins the plan
• Whenever prescription drug coverage ends or changes so that it is no longer creditable or becomes creditable
• Upon request