HCR Update: External Claims & Appeals; Workplace Health Funds

We have worked with our partners at UBA to provide you the most recent Health Care Reform Update:

EBSA Issues Amendments to Interim Final Rules and Model Notices on Internal Claims and Appeals and External Review Processes

The U.S. Employee Benefit Security Administration (EBSA) and Department of Health and Human Services (HHS) issued amendments to the Interim Final Rules implementing the requirements regarding internal claims and appeals and external review processes for group health plans and health insurance coverage in the group and individual markets under provisions of the Patient Protection and Affordable Care Act (PPACA).

These rules are intended to respond to feedback from stakeholders on the interim final regulations and to assist plans and issuers in coming into full compliance with the law through an orderly implementation process. Public comments on the amendment to the regulations are requested and must be submitted within 30 days.

The amendments focus primarily on six issues:

• Expedited notification of benefit determinations involving urgent care
• Additional notice requirements with respect to notice of adverse benefit determinations or final internal adverse benefit determination
• Deemed exhaustion of internal claims and appeals processes
• Providing notices in a culturally and linguistically appropriate manner
• Duration of transition period for State external review processes
• Scope of the Federal External Review Process

Some highlights:

Urgent care decisions
One change involves the amount of time health care plan enrollees have to be notified of an urgent care coverage decision.

• Last year, regulators said enrollees would have to be notified of an urgent care decision within 24 hours of receipt of a claim.
• But in a joint amendment to the 2010 regulations published in Friday's Federal Register, the Health and Human Services, Labor and Treasury Departments said they will allow plans to make notification of coverage decisions within 72 hours, closely following a Labor Department rule. Regulators, though, noted that the 72-hour limit is a maximum "and that in cases where a decision must be made more quickly based on the medical exigencies involved, the requirement remains that the decision should be made sooner than 72 hours after the receipt of the claim," according to the rules published in Fridays' Federal Register.

Notifications in languages besides English
The latest rules also amend a requirement that notices of available and external claims appeal processes and review be provided in a "culturally and linguistically appropriate manner."

• Under the previous rules, the requirement to provide notices in a language other than English was based on the percentage of plan enrollees who were literate in a common non-English language. For plans that cover more than 100 participants, the threshold was 10 percent of plan participants, or 500 participants, whichever was less.
• Under the latest rules, the requirement applies if at least 10 percent of the population residing in a county where an employer's health care plan enrollees reside are literate in the same non-English language. Currently, 255 U.S. counties meet this standard, including 78 of which are in Puerto Rico, according to the rules.

 The agencies also released additional guidance and revised model notices related to the amended interim final rules.

• Technical Release 2011-02 
• Revised Model Notice of Adverse Benefit Determination
• Revised Model Notice of Final Internal Adverse Benefit Determination
• Revised Model Notice of Final External Review Decision
• Updated List of Consumer Assistance Programs, as of May 23, 2011

$10 Million in Affordable Care Act Funds to Help Create Workplace Health Programs
The U.S. Department of Health and Human Services announced today the availability of $10 million to establish and evaluate comprehensive workplace health promotion programs across the nation to improve the health of American workers and their families. The initiative, with funds from the Affordable Care Act's Prevention and Public Health Fund, is aimed at improving workplace environments so that they support healthy lifestyles and reduce risk factors for chronic diseases like heart disease, cancer, stroke, and diabetes.

Funds will be awarded through a competitive contract to an organization with the expertise and capacity to work with groups of employers across the nation to develop and expand workplace health programs in small and large worksites. Participating companies will educate employees about good health practices and establish work environments that promote physical activity and proper nutrition and discourage tobacco use -- the key lifestyle behaviors that reduce employees' risk for chronic disease.

Project funds will support evidence-based initiatives to build worksite capacity and improve workplace culture in support of health. Examples of such strategies include establishing tobacco-free campus policies, promoting flextime to allow employees to be more physically active, and offering more healthy food choices in worksite cafeterias and vending machines. A core principle of the initiative is to maximize employee engagement in designing and implementing the programs so they have the greatest chances of success.

Organizations interested in submitting proposals for the Comprehensive Health Programs to Address Physical Activity, Nutrition, and Tobacco Use in the Workplace can find more information at www.fbo.gov. The application deadline is Aug. 8, 2011. A separate funding opportunity is available for a national evaluation of the initiative and can also be found at www.fbo.gov.