For purposes of compliance with the interim final regulations, a health insurance issuer offering health insurance coverage in connection with a group health plan is subject to the Department of Labor claims procedure regulation to the same extent as if it were a group health plan.
However, the interim final regulations also set forth six new requirements:
- The definition of an adverse benefit determination now also includes a rescission of coverage;
- A plan or issuer must notify a claimant of a benefit determination (whether adverse or not) with respect to a claim involving urgent care (as defined in the DoL claims procedure regulation) as soon as possible, taking into account the medical exigencies, but not later than 24 hours after the receipt of the claim by the plan or health insurance coverage, unless the claimant fails to provide sufficient information to determine whether, or to what extent, benefits are covered or payable under the plan or health insurance coverage;
- The interim final regulations provide additional criteria to ensure that a claimant receives a full and fair review;
- The interim final regulations provide new criteria with respect to avoiding conflicts of interest;
- There are new standards regarding notice to enrollees; and
- In the case of a plan or issuer that fails to strictly adhere to all the requirements of the internal claims and appeals process with respect to a claim, the claimant is deemed to have exhausted the internal claims and appeals process, regardless of whether the plan or issuer asserts that it substantially complied with these requirements or that any error it committed was minimal.
The interim final regulations also set forth rules related to the form and manner of providing notices in connection with internal claims and appeals and external review processes.
The regulations provide rules for determining whether a State external review process or a Federal external review process applies, as well as guidance regarding each process. For plans and issuers subject to existing State external review processes, the regulations include a transition period until July 1, 2011. For plans and issuers not subject to an existing State external review process (including self-insured plans), a Federal process will apply for plan years (in the individual market, policy years) beginning on or after September 23, 2010.
The new rules will generally affect health insurance issuers; group health plans; and participants, beneficiaries, and enrollees in health insurance coverage and in group health plans. They generally apply to group health plans and group health insurance issuers for plan years beginning on or after September 23, 2010, and generally apply to individual health insurance issuers for policy years beginning on or after September 23, 2010.Text of the interim final regulations, including instructions for making comment, can be found at http://www.dol.gov/ebsa. A fact sheet is here.