On Tuesday October 12th, the IRS issued a notice providing interim relief to employers regarding reporting the costs of group health plan coverage to employees (Notice 2010-69). Under the notice, notification to employees on Form W-2 will not be required for 2011. The IRS also posted a draft 2011 Form W-2 on its site.
The health care reform legislation enacted in March requires employers to include the aggregate cost of applicable employer-sponsored health care coverage on employees’ W-2s for tax years starting on or after Jan. 1, 2011 (new IRC § 6051(a)(14)). The IRS decided that employers need additional time to make changes to their payroll systems and procedures to comply with this rule. Therefore, the notice says the reporting requirement will not be mandatory for W-2s issued for 2011 and employers will not be subject to penalties for failure to meet the requirements of section 6051(a)(14) for 2011 tax years.
Employers who choose to report 2011 health care coverage costs to their employees will do so in Box 12 using the code “DD.” The IRS anticipates issuing guidance on the reporting requirement before the end of the year.
To read the full article click here
Monday, October 25, 2010
Friday, October 8, 2010
Health Care Reform: Tips for Open Enrollment
The first round of health care reform changes under the Patient Protection and Affordable Care Act of 2010 ("PPACA") goes into effect January 1, 2011 for calendar year group health plans. It's now crunch time for employers pulling together their open enrollment materials for 2011.
Click here to read more.
Click here to read more.
Wednesday, September 15, 2010
Judge Sets Hearing on Suit Challenging Health Reforms
PENSACOLA, Fla. (Reuters)—A Florida judge said Tuesday he would hear arguments Dec. 16 on a lawsuit by 20 U.S. states seeking to block President Barack Obama's overhaul of the U.S. health care system.
U.S. District Judge Roger Vinson, who is weighing a motion by the Justice Department to dismiss the lawsuit, ordered the follow-up hearing on the lawsuit led by Florida and involving 19 other states, which was originally filed in March by mostly Republican state attorneys general.
Judge Vinson said he would formally rule on the dismissal motion by Oct. 14, but Florida Attorney General Bill McCollum said the judge had already strongly indicated that the case would not be dismissed.
"The judge's apparent decision today means we will proceed," Mr. McCollum told reporters.
He was referring to what transpired during nearly two hours of arguments in Vinson's Pensacola courtroom Tuesday. During the hearing, the judge said he would likely reject "at least one" of the government's motions for dismissal of the case, but he did not elaborate.
An adverse ruling on the dismissal would be a setback for the White House, forcing it to defend its reforms in the middle of a tough campaign before the November midterm congressional elections.
The lawsuit claims the sweeping reform of the $2.5 trillion U.S. health care system, pushed through by President Obama's fellow Democrats in Congress after months of bitter partisan wrangling, violates state government rights in the Constitution and will force massive new spending on hard-pressed state governments.
The new health care law is a cornerstone of President Obama's domestic agenda and aims to expand health insurance for millions more Americans while curbing costs. Obama officials have insisted it is constitutional and is necessary to stem huge projected increases in health care expenses.
To view the full article click here
U.S. District Judge Roger Vinson, who is weighing a motion by the Justice Department to dismiss the lawsuit, ordered the follow-up hearing on the lawsuit led by Florida and involving 19 other states, which was originally filed in March by mostly Republican state attorneys general.
Judge Vinson said he would formally rule on the dismissal motion by Oct. 14, but Florida Attorney General Bill McCollum said the judge had already strongly indicated that the case would not be dismissed.
"The judge's apparent decision today means we will proceed," Mr. McCollum told reporters.
He was referring to what transpired during nearly two hours of arguments in Vinson's Pensacola courtroom Tuesday. During the hearing, the judge said he would likely reject "at least one" of the government's motions for dismissal of the case, but he did not elaborate.
An adverse ruling on the dismissal would be a setback for the White House, forcing it to defend its reforms in the middle of a tough campaign before the November midterm congressional elections.
The lawsuit claims the sweeping reform of the $2.5 trillion U.S. health care system, pushed through by President Obama's fellow Democrats in Congress after months of bitter partisan wrangling, violates state government rights in the Constitution and will force massive new spending on hard-pressed state governments.
The new health care law is a cornerstone of President Obama's domestic agenda and aims to expand health insurance for millions more Americans while curbing costs. Obama officials have insisted it is constitutional and is necessary to stem huge projected increases in health care expenses.
To view the full article click here
Friday, September 10, 2010
Guidance Issued on 2011 FSA / HSA Changes
The Patient Protection and Affordable Care Act (PPACA) changed the requirements related to reimbursements for over-the-counter (OTC) drugs. These changes affect health FSAs, HRAs, HSAs and Archer MSAs, which will need a prescription to reimburse the costs of OTC drugs purchased after December 31, 2010.
On September 3, 2010, the IRS released IRS Notice 2010-59, which provides additional information on this requirement. The notice states:
· Reimbursement is restricted to prescribed drugs, insulin and OTC drugs that have a
prescription;
· Health FSA and HRA debit cards cannot be used for OTC drugs, except as provided in the notice; and
· Required cafeteria plan amendments must be adopted by June 30, 2011 and can be retroactively effective.
See www.ecfc.org/files/legislative-news/n-10-59.pdf for a copy of the Notice.
IRS NOTICE 2010-59
General Rule
The Notice provides guidance on Section 9003 of PPACA, which revises the definition of “medical expenses” for employer-provided accident and health plans, including health flexible spending arrangements (health FSAs) and health reimbursement arrangements (HRAs). PPACA Section 9003 also revises the definition of “qualified medical expenses” for health savings accounts (HSAs) and Archer medical savings accounts (Archer MSAs). Section 9003 applies after December 31, 2010.
Under these rules, tax-free payment or reimbursement is only available after December 31, 2010, for expenses incurred for a medicine or drug if the medicine or drug is a prescribed drug (determined without regard to whether the drug is available without a prescription) or is insulin. This means that these expenses may be paid or reimbursed by an employer-provided plan (including a health FSA or HRA) or reimbursed tax-free by an HSA or Archer MSA if the medicine or drug:
· Requires a prescription;
· Is an OTC medicine or drug and the individual obtains a prescription; OR
· Is insulin.
Note that expenses incurred for OTC medicines or drugs purchased without a prescription before January 1, 2011, may be reimbursed tax-free at any time, pursuant to the terms of the plan.
What Is a Prescription?
For purposes of these rules, the Notice clarifies that a prescription means a written or electronic order for a medicine or drug that meets the legal requirements of a prescription in the state in which the medical expense is incurred and that is issued by an individual who is legally authorized to issue a prescription in that state.
What About Other OTC Items?
The Notice makes clear that the requirement to get a prescription does not apply to OTC items that are not medicines or drugs, including equipment such as crutches, supplies such as bandages, and diagnostic devices such as blood sugar test kits. These items can qualify for medical care if they otherwise meet the tax code’s definition of medical care, which includes expenses for the diagnosis, cure, mitigation, treatment, or prevention of disease, or for the purpose of affecting any structure or function of the body. However, expense for items that are merely beneficial to the general health of an individual, such as an expenditure for a vacation, are not expenses for medical care.
Rules for Debit Cards
In most cases, health FSA and HRA debit cards will not be able to be used to purchase OTC medicines or drugs, effective January 1, 2011. This is because current debit card systems are not capable of recognizing and substantiating that the OTC medicine or drug were prescribed. However, see below for an exception for purchases at certain pharmacies. Also, debit cards may continue to be used for medical expenses other than OTC medicines or drugs.
In order to facilitate the significant changes to existing systems necessary to reflect the new rules, the IRS will not challenge the use of debit cards for expenses incurred through January 15, 2011, as long as the use follows existing rules. However, on and after January 16, 2011, OTC medicine or drug purchases at all providers and merchants must be substantiated before reimbursement may be made. This is the case even if the provider or merchant has an inventory information approval system (IIAS). Substantiation is accomplished by submitting the prescription (or a copy of the prescription or other documentation that a prescription has been issued) for the OTC medicine or drug and other information from an independent third party that satisfies existing requirements.
The Notice gives examples of documentation that would satisfy the substantiation requirements for OTC medicines or drugs:
· A customer receipt issued by a pharmacy which identifies the name of the purchaser (or the name of the person for whom the prescription applies), the date and amount of the purchase and an Rx number.
· A similar receipt without an Rx number that is accompanied by a copy of the related prescription.
As noted above, there is an exception to the restrictions on debit card use for certain pharmacies. Prior IRS guidance (Notice 2007-2) provides that health FSA and HRA debit cards may be used at a pharmacy that does not have an IIAS if 90 percent of the store’s gross receipts during the prior taxable year consists of items which qualify as expenses for medical care under Internal Revenue Code Section 213(d). The Notice states that, until further guidance is issued, debit cards may be used at a pharmacy that satisfies the 90-percent test to purchase OTC medicines or drugs that have been prescribed, provided that substantiation is properly submitted in accordance with the terms of the plan. The prescription (or a copy of the prescription or other documentation that a prescription has been issued) and other information from an independent third party must be included. For the purpose of determining whether a pharmacy meets the 90-percent test, sales of OTC medicines and drugs at the pharmacy may continue to be taken into account after December 31, 2010.
Transition Rule for Cafeteria Plans
Cafeteria plans may need to be amended to follow the new requirements for OTC medicines and drugs. In general cafeteria plan amendments may be effective only prospectively. However, the Notice states that, notwithstanding the general rule against retroactive amendments, an amendment to conform to the cafeteria plan to the new OTC drug requirements that is adopted no later than June 30, 2011, may be made effective retroactively for expenses occurred after December 31, 2010 (or after January 15, 2011 for health FSA and HRA debit card purchases).
Effective Dates
For expenses incurred after December 31, 2010, payments or reimbursements for medicines or drugs from an employer-provided accident and health plan, including a health FSA or HRA, are restricted to prescribed drugs, insulin, and OTC drugs that are prescribed.
This effective date applies regardless of whether the plan year for the employer’s plan is a fiscal or calendar year or whether there is no plan year (or other coverage period in the case of an HRA), and regardless of any applicable grace period for a health FSA.
Tax-free distributions for qualified medical expenses from an HSA or Archer MSA for medicines or drugs purchased after December 31, 2010, are restricted to prescribed drugs, insulin and OTC medicines or drugs that are prescribed.
On September 3, 2010, the IRS released IRS Notice 2010-59, which provides additional information on this requirement. The notice states:
· Reimbursement is restricted to prescribed drugs, insulin and OTC drugs that have a
prescription;
· Health FSA and HRA debit cards cannot be used for OTC drugs, except as provided in the notice; and
· Required cafeteria plan amendments must be adopted by June 30, 2011 and can be retroactively effective.
See www.ecfc.org/files/legislative-news/n-10-59.pdf for a copy of the Notice.
IRS NOTICE 2010-59
General Rule
The Notice provides guidance on Section 9003 of PPACA, which revises the definition of “medical expenses” for employer-provided accident and health plans, including health flexible spending arrangements (health FSAs) and health reimbursement arrangements (HRAs). PPACA Section 9003 also revises the definition of “qualified medical expenses” for health savings accounts (HSAs) and Archer medical savings accounts (Archer MSAs). Section 9003 applies after December 31, 2010.
Under these rules, tax-free payment or reimbursement is only available after December 31, 2010, for expenses incurred for a medicine or drug if the medicine or drug is a prescribed drug (determined without regard to whether the drug is available without a prescription) or is insulin. This means that these expenses may be paid or reimbursed by an employer-provided plan (including a health FSA or HRA) or reimbursed tax-free by an HSA or Archer MSA if the medicine or drug:
· Requires a prescription;
· Is an OTC medicine or drug and the individual obtains a prescription; OR
· Is insulin.
Note that expenses incurred for OTC medicines or drugs purchased without a prescription before January 1, 2011, may be reimbursed tax-free at any time, pursuant to the terms of the plan.
What Is a Prescription?
For purposes of these rules, the Notice clarifies that a prescription means a written or electronic order for a medicine or drug that meets the legal requirements of a prescription in the state in which the medical expense is incurred and that is issued by an individual who is legally authorized to issue a prescription in that state.
What About Other OTC Items?
The Notice makes clear that the requirement to get a prescription does not apply to OTC items that are not medicines or drugs, including equipment such as crutches, supplies such as bandages, and diagnostic devices such as blood sugar test kits. These items can qualify for medical care if they otherwise meet the tax code’s definition of medical care, which includes expenses for the diagnosis, cure, mitigation, treatment, or prevention of disease, or for the purpose of affecting any structure or function of the body. However, expense for items that are merely beneficial to the general health of an individual, such as an expenditure for a vacation, are not expenses for medical care.
Rules for Debit Cards
In most cases, health FSA and HRA debit cards will not be able to be used to purchase OTC medicines or drugs, effective January 1, 2011. This is because current debit card systems are not capable of recognizing and substantiating that the OTC medicine or drug were prescribed. However, see below for an exception for purchases at certain pharmacies. Also, debit cards may continue to be used for medical expenses other than OTC medicines or drugs.
In order to facilitate the significant changes to existing systems necessary to reflect the new rules, the IRS will not challenge the use of debit cards for expenses incurred through January 15, 2011, as long as the use follows existing rules. However, on and after January 16, 2011, OTC medicine or drug purchases at all providers and merchants must be substantiated before reimbursement may be made. This is the case even if the provider or merchant has an inventory information approval system (IIAS). Substantiation is accomplished by submitting the prescription (or a copy of the prescription or other documentation that a prescription has been issued) for the OTC medicine or drug and other information from an independent third party that satisfies existing requirements.
The Notice gives examples of documentation that would satisfy the substantiation requirements for OTC medicines or drugs:
· A customer receipt issued by a pharmacy which identifies the name of the purchaser (or the name of the person for whom the prescription applies), the date and amount of the purchase and an Rx number.
· A similar receipt without an Rx number that is accompanied by a copy of the related prescription.
As noted above, there is an exception to the restrictions on debit card use for certain pharmacies. Prior IRS guidance (Notice 2007-2) provides that health FSA and HRA debit cards may be used at a pharmacy that does not have an IIAS if 90 percent of the store’s gross receipts during the prior taxable year consists of items which qualify as expenses for medical care under Internal Revenue Code Section 213(d). The Notice states that, until further guidance is issued, debit cards may be used at a pharmacy that satisfies the 90-percent test to purchase OTC medicines or drugs that have been prescribed, provided that substantiation is properly submitted in accordance with the terms of the plan. The prescription (or a copy of the prescription or other documentation that a prescription has been issued) and other information from an independent third party must be included. For the purpose of determining whether a pharmacy meets the 90-percent test, sales of OTC medicines and drugs at the pharmacy may continue to be taken into account after December 31, 2010.
Transition Rule for Cafeteria Plans
Cafeteria plans may need to be amended to follow the new requirements for OTC medicines and drugs. In general cafeteria plan amendments may be effective only prospectively. However, the Notice states that, notwithstanding the general rule against retroactive amendments, an amendment to conform to the cafeteria plan to the new OTC drug requirements that is adopted no later than June 30, 2011, may be made effective retroactively for expenses occurred after December 31, 2010 (or after January 15, 2011 for health FSA and HRA debit card purchases).
Effective Dates
For expenses incurred after December 31, 2010, payments or reimbursements for medicines or drugs from an employer-provided accident and health plan, including a health FSA or HRA, are restricted to prescribed drugs, insulin, and OTC drugs that are prescribed.
This effective date applies regardless of whether the plan year for the employer’s plan is a fiscal or calendar year or whether there is no plan year (or other coverage period in the case of an HRA), and regardless of any applicable grace period for a health FSA.
Tax-free distributions for qualified medical expenses from an HSA or Archer MSA for medicines or drugs purchased after December 31, 2010, are restricted to prescribed drugs, insulin and OTC medicines or drugs that are prescribed.
Wednesday, September 1, 2010
First Round of Approved Applications for Early Retiree Reinsurance Program Released
Wednesday, August 25, 2010
Additional Clarification on New Appeals Process Requirements
WASHINGTON—Interim final rules describing the appeals process and external claims review that non-grandfathered self-insured group health plans must follow under the health care reform law have been issued by the Departments of Labor, Health and Human Services and the Internal Revenue Service.
The rules clarify certain issues that were not addressed in previous regulations.
The Patient Protection and Affordable Care Act mandates that employees in self-funded health plans be able to request a “federal external review” of coverage if a claim or benefit is denied through internal reviews conducted by employers and plan administrators.
Under the interim final rules, which were issued Monday and apply to plan years beginning on or after Sept. 23, 2010, a group health plan must give claimants up to four months to request an external review after an adverse claim or benefit decision. A preliminary review of that request must be conducted within five business days of the receipt of that request, and the plan must issue a written notification to the claimant within one business day after the preliminary review has been completed.
If the preliminary review finds the need for an external review, the request must be referred to an independent review organization accredited by URAC or a similar nationally recognized accrediting organization. To ensure there is no bias in the external review process, benefit plans are required to contract with at least three of these independent review organizations and rotate claims assignments among them. In addition, the review organizations cannot be eligible for any financial incentives based on the likelihood that they would support denial of benefits.
An expedited external review process is prescribed for situations requiring immediate medical care, including urgent care and for those in which denial of payment for treatment would jeopardize the claimant's ability to regain maximum function.
The interim final rules also outline specific requirements that group benefit plans must include in their contracts with independent review organizations, as well as the type of information and documents that the review organizations must consider in making decisions.
To view the full article click here.
The rules clarify certain issues that were not addressed in previous regulations.
The Patient Protection and Affordable Care Act mandates that employees in self-funded health plans be able to request a “federal external review” of coverage if a claim or benefit is denied through internal reviews conducted by employers and plan administrators.
Under the interim final rules, which were issued Monday and apply to plan years beginning on or after Sept. 23, 2010, a group health plan must give claimants up to four months to request an external review after an adverse claim or benefit decision. A preliminary review of that request must be conducted within five business days of the receipt of that request, and the plan must issue a written notification to the claimant within one business day after the preliminary review has been completed.
If the preliminary review finds the need for an external review, the request must be referred to an independent review organization accredited by URAC or a similar nationally recognized accrediting organization. To ensure there is no bias in the external review process, benefit plans are required to contract with at least three of these independent review organizations and rotate claims assignments among them. In addition, the review organizations cannot be eligible for any financial incentives based on the likelihood that they would support denial of benefits.
An expedited external review process is prescribed for situations requiring immediate medical care, including urgent care and for those in which denial of payment for treatment would jeopardize the claimant's ability to regain maximum function.
The interim final rules also outline specific requirements that group benefit plans must include in their contracts with independent review organizations, as well as the type of information and documents that the review organizations must consider in making decisions.
To view the full article click here.
Friday, August 6, 2010
Guidance Provided Regarding Health Care Reform's New Appeal Requirements
Regulations issued by the Departments of Health and Human Services, Labor, and the Treasury will standardize both an internal process and an external process that patients can use to appeal decisions made by their health plan. The rules issued on July 23, 2010 will provide uniformity to the existing patchwork of protections that apply to only some plans in some States, and simplify the system for consumers.
It appears that the bulk of responsibility for implementation for these processes' will fall on the shoulders of the insurance companies and the states. Employers will need to ensure that their employees are aware of these avenues of appeals.
Below is an excerpt from the fact sheet released by the Department of Health & Human Services:
The new rules issued by the Departments of Health and Human Services, Labor, and the Treasury will standardize both an internal process and an external process that patients can use to appeal decisions made by their health plan.
Today, if your health plan tells you it won’t cover a treatment your doctor recommends, or it refuses to pay the bill for your child’s last trip to the emergency room, you may not know where to turn. Most health plans have a process that lets you appeal the decision within the plan through an "internal appeal" – but depending on your State’s laws and your type of coverage, there’s no guarantee that the process will be swift and objective. Moreover, if you lose your internal appeal, you may not be able to ask for an "external appeal" to an independent reviewer.
The rules issued today will end the patchwork of protections that apply to only some plans in some States, and simplify the system for consumers. And they will ensure that all consumers in new health plans have access to internal and external appeals processes that are clearly defined, impartial, and designed to ensure that, when health care is needed and covered, consumers get it.
Internal Appeals:
The internal appeals process will guarantee a venue where consumers may present information their health plan might not have been aware of, giving families a straightforward way to clear up misunderstandings. Under the new rules, new health plans beginning on or after September 23, 2010 must have 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.
External Appeals:
If a patient’s internal appeal is denied, patients in new plans will have the right to appeal all denied claims to an independent reviewer not employed by their health plan. External appeals have helped consumers get the care they deserve: one study found that – in States that had external appeals – consumers won their external appeal against the insurance company 45% of the time.
While 44 States provide for some form of external appeal, the laws governing these processes vary greatly and fail to cover millions of Americans. The new rules will ensure that consumers with new health coverage in all States have access to a standard external appeals process that meets high standards for full and fair review.
These standards were established by the National Association of Insurance Commissioners (NAIC). States are encouraged to make changes in their external appeals laws to adopt these standards before July 1, 2011. The NAIC standards call for:
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.
If State laws don’t meet these standards, consumers in those States will be protected by comparable Federal external appeals standards. In addition, people in health plans that are not subject to State law – including new self-insured employer plans – will be protected by the new Federal standards.
It appears that the bulk of responsibility for implementation for these processes' will fall on the shoulders of the insurance companies and the states. Employers will need to ensure that their employees are aware of these avenues of appeals.
Below is an excerpt from the fact sheet released by the Department of Health & Human Services:
The new rules issued by the Departments of Health and Human Services, Labor, and the Treasury will standardize both an internal process and an external process that patients can use to appeal decisions made by their health plan.
Today, if your health plan tells you it won’t cover a treatment your doctor recommends, or it refuses to pay the bill for your child’s last trip to the emergency room, you may not know where to turn. Most health plans have a process that lets you appeal the decision within the plan through an "internal appeal" – but depending on your State’s laws and your type of coverage, there’s no guarantee that the process will be swift and objective. Moreover, if you lose your internal appeal, you may not be able to ask for an "external appeal" to an independent reviewer.
The rules issued today will end the patchwork of protections that apply to only some plans in some States, and simplify the system for consumers. And they will ensure that all consumers in new health plans have access to internal and external appeals processes that are clearly defined, impartial, and designed to ensure that, when health care is needed and covered, consumers get it.
Internal Appeals:
The internal appeals process will guarantee a venue where consumers may present information their health plan might not have been aware of, giving families a straightforward way to clear up misunderstandings. Under the new rules, new health plans beginning on or after September 23, 2010 must have 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.
External Appeals:
If a patient’s internal appeal is denied, patients in new plans will have the right to appeal all denied claims to an independent reviewer not employed by their health plan. External appeals have helped consumers get the care they deserve: one study found that – in States that had external appeals – consumers won their external appeal against the insurance company 45% of the time.
While 44 States provide for some form of external appeal, the laws governing these processes vary greatly and fail to cover millions of Americans. The new rules will ensure that consumers with new health coverage in all States have access to a standard external appeals process that meets high standards for full and fair review.
These standards were established by the National Association of Insurance Commissioners (NAIC). States are encouraged to make changes in their external appeals laws to adopt these standards before July 1, 2011. The NAIC standards call for:
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.
If State laws don’t meet these standards, consumers in those States will be protected by comparable Federal external appeals standards. In addition, people in health plans that are not subject to State law – including new self-insured employer plans – will be protected by the new Federal standards.
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