EBSA Extends Compliance Grace Periods for Certain Health Plan Obligations

On March 18, the DOL’s Employee Benefits Security Administration (EBSA) issued a new guidance document (Technical Release 2011-01) that modifies and extends the enforcement grace periods for compliance with certain Affordable Care Act provisions dealing with internal appeals and external review of denied claims that were provided to non-grandfathered health plans in Technical Release 2010-02, published in September of last year.  Specifically, the earlier guidance gave health insurance plans and issuers until July 1, 2011 to comply with certain requirements set forth in the interim final regulations that dictate procedures for internal appeals of adverse claims decisions and require an independent external appeal process for denied health plan claims. According to the EBSA, after reviewing comments provided in response to the interim regulations, the agency has decided to issue an amendment to that interim rule. The guidance and compliance grace period set forth in the new technical release document is designed to serve as a bridge until that regulatory amendment is published.

The 12-page guidance document enumerates and briefly describes the new standards for internal claims and appeals processes established by the interim final regulations, and details the corresponding extended enforcement date. Generally, the technical release extends the enforcement grace period until plan years beginning on or after January 1, 2012 with respect to many of the new regulatory standards.

In addition, one requirement for plans and issuers in states in which an office of health consumer assistance program or ombudsman is operational is to provide such contact information to claimants. To assist with this obligation, the EBSA has included an appendix to the Technical Release that lists this contact information by state.

According to the EBSA, the overall purpose of the Technical Release is to:

ensure that plan participants and beneficiaries are promptly accorded the important protections under the Affordable Care Act that provide for fuller and fairer processing of claims, the right to appeal claims that are denied, and the right to obtain effective external review of denials on appeal. The Departments are working with employer plan sponsors, health insurance issuers, States, and other stakeholders to assist them in coming into compliance with the law through an orderly and expeditious implementation process. Accordingly, this guidance seeks to minimize both cost and delay, and avoid confusion for participants and plans alike.

This entry was written by Ilyse Schuman.